Basic Information
Provider Information | |||||||||
NPI: | 1891449930 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOUZE-DIXON | ||||||||
FirstName: | SHANNETTA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOUZE-DIXON | ||||||||
OtherFirstName: | SHANNETTA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DNP, FNP-BC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 87742 | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481870742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7347560877 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 880 W LONG LAKE RD | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480984504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885625442 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2022 | ||||||||
LastUpdateDate: | 08/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704308259 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.