Individual
SHANNON DOHERTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
30200 TELEGRAPH RD, SUITE 220, BINGHAM FARMS, MI 48025-4502
(248) 258-5058
Mailing address
5445 MYRON RD, GRANT TOWNSHIP, MI 48032-2403
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
4704140193
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104838402
—
MI
01
—
P00311232
RAILROAD MEDICARE
MI
Enumeration date
04/25/2006
Last updated
04/12/2017
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