Basic Information
| Provider Information | |||||||||
| NPI: | 1376158311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | HAVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1052 N MONROE ST | ||||||||
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| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342429550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1502 N MONROE ST. | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342429550 | ||||||||
| FaxNumber: | 7349712303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 4704329812 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.