Provider Demographics
NPI:1891575106
Name:BRZAK, SHANNON (NP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRZAK
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42557 WOODWARD AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5206
Mailing Address - Country:US
Mailing Address - Phone:248-454-1004
Mailing Address - Fax:
Practice Address - Street 1:42557 WOODWARD AVE STE 130
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5206
Practice Address - Country:US
Practice Address - Phone:248-454-1004
Practice Address - Fax:833-450-6345
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704323358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily