Basic Information
| Provider Information | |||||||||
| NPI: | 1568615888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | MARQUISA | ||||||||
| MiddleName: | DANAE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | B.A,M.B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 LAKEWOOD ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482153152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138227986 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4875 COPLIN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138221135 | ||||||||
| FaxNumber: | 3138221157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | 6803085735 | MI | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.