Provider Demographics
NPI:1366047896
Name:BEAGAN, SHANNON MARIE
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:BEAGAN
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 1:16721 PHILOMENE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2419
Mailing Address - Country:US
Mailing Address - Phone:313-289-1478
Mailing Address - Fax:
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:313-576-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274132363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner