Provider Demographics
NPI:1215445820
Name:NARD, SHANTALE
Entity type:Individual
Prefix:MISS
First Name:SHANTALE
Middle Name:
Last Name:NARD
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 1:21465 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2823
Mailing Address - Country:US
Mailing Address - Phone:313-265-6985
Mailing Address - Fax:
Practice Address - Street 1:21465 SYRACUSE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2823
Practice Address - Country:US
Practice Address - Phone:313-265-6985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide