Provider Demographics
NPI:1154955219
Name:DIETRICK, SHAWNA DAVELLA
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:DAVELLA
Last Name:DIETRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74083
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-0083
Mailing Address - Country:US
Mailing Address - Phone:810-308-7991
Mailing Address - Fax:
Practice Address - Street 1:35675 GARNER ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-4129
Practice Address - Country:US
Practice Address - Phone:810-308-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID362765135841385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID362765135841OtherIDENTIFICATION