Basic Information
| Provider Information | |||||||||
| NPI: | 1497211338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONUCCI | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 TYLER ROAD | ||||||||
| Address2: | |||||||||
| City: | LASALLE | ||||||||
| State: | ONTARIO | ||||||||
| PostalCode: | N9J3X2 | ||||||||
| CountryCode: | CA | ||||||||
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| Practice Location | |||||||||
| Address1: | 17187 SCHAEFER HWY | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482354132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139606605 | ||||||||
| FaxNumber: | 2485958269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2019 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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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 | 363L00000X | 4704261629 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.