Provider Demographics
NPI:1538621073
Name:BALL, SHANNON M (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BALL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:818 W KING ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2117
Mailing Address - Country:US
Mailing Address - Phone:989-723-3168
Mailing Address - Fax:989-725-2962
Practice Address - Street 1:818 W KING ST STE 201
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2117
Practice Address - Country:US
Practice Address - Phone:989-723-3168
Practice Address - Fax:989-725-2962
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270214363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner