Provider Demographics
NPI:1306292255
Name:CLANCY, SHANNON M
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:M
Last Name:CLANCY
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 1:37634 JONQUIL CT
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1980
Mailing Address - Country:US
Mailing Address - Phone:734-474-7594
Mailing Address - Fax:
Practice Address - Street 1:37634 JONQUIL CT
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1980
Practice Address - Country:US
Practice Address - Phone:734-474-7594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other