Basic Information
| Provider Information | |||||||||
| NPI: | 1134872823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAKROUB | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398 ANNALIA DR | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053612041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11650 BELLEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481113380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346999888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2022 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F01221220 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.