Provider Demographics
NPI:1588280663
Name:COUSINEAU, SHANNON KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 GREEN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-1754
Mailing Address - Country:US
Mailing Address - Phone:847-791-2015
Mailing Address - Fax:
Practice Address - Street 1:14165 N FENTON RD STE 201A
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1584
Practice Address - Country:US
Practice Address - Phone:810-853-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704348540163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse