Provider Demographics
NPI:1902121361
Name:BREDOW-SHAWCROSS, CHARISSA ALICE (NP)
Entity Type:Individual
Prefix:MS
First Name:CHARISSA
Middle Name:ALICE
Last Name:BREDOW-SHAWCROSS
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 1:18917 JOY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3050
Mailing Address - Country:US
Mailing Address - Phone:313-581-7773
Mailing Address - Fax:313-581-7793
Practice Address - Street 1:18917 JOY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3050
Practice Address - Country:US
Practice Address - Phone:313-581-7773
Practice Address - Fax:313-581-7793
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115714363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health