Basic Information
| Provider Information | |||||||||
| NPI: | 1780121145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACOVIC | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36267 26 MILE ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | LENOX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480483166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867161371 | ||||||||
| FaxNumber: | 5867164855 | ||||||||
| Practice Location | |||||||||
| Address1: | 36267 26 MILE ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | LENOX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480483166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867161371 | ||||||||
| FaxNumber: | 5867164855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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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 | 363LF0000X | 4704240822 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.