Provider Demographics
NPI:1588556815
Name:VANDERARK, SHANNIN B
Entity type:Individual
Prefix:
First Name:SHANNIN
Middle Name:B
Last Name:VANDERARK
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 1:3774 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9550
Mailing Address - Country:US
Mailing Address - Phone:269-428-2799
Mailing Address - Fax:
Practice Address - Street 1:3774 HOLLYWOOD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9550
Practice Address - Country:US
Practice Address - Phone:269-428-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007966225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics