Basic Information
| Provider Information | |||||||||
| NPI: | 1184991713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONIECZKI | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | RN, MSN, CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTIONE UHC 5D | ||||||||
| Address2: | UNIVERDITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN ST. | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MI | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139932950 | ||||||||
| FaxNumber: | 3137455237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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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 | 363LP0200X | 4704261113 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.