Basic Information
| Provider Information | |||||||||
| NPI: | 1417361361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | CYNTHIA | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23747 GLENBROOK ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480822505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869041399 | ||||||||
| FaxNumber: | 5864156580 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480604477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 4704270589 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LA2200X | 4704270589 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.