Shanise Yvonne Petticord

Primary specialty

Licensed Practical NurseTaxonomy code 164W00000X

License

4703091434 Issued in MI

Practice address

5736 Audubon Rd
Detroit, MI 48224-2665

Phone

(313) 624-1067

NPI assigned

Apr 8, 2024

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Co-Rect Co-Nect Reps LLC

  • Home Health Agency
  • Detroit, MI
  • NPI 1780437186
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1712534400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712534400000",
    "number": "1700639101",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5736 AUDUBON RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482242665",
            "telephone_number": "313-624-1067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5736 AUDUBON RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482242665",
            "telephone_number": "313-624-1067"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTICORD",
        "first_name": "SHANISE",
        "middle_name": "YVONNE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-04-08",
        "last_updated": "2024-04-08",
        "certification_date": "2024-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "164W00000X",
            "taxonomy_group": "",
            "desc": "Licensed Practical Nurse",
            "state": "MI",
            "license": "4703091434",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Justin David Petrusak, LMSW
• John Paul Petrykowski, DO
• Robert Pettaway
• Jimeka Pettes, MD
• Shania Petticord
• Karen Pettiford
• Roshelle Deshawn Pettiford
• Rebecca Pettinger, LLPC
• Valerie Pettis
• Willie James Pettiway Sr., MD

• Licensed Practical Nurse in Detroit, MI
• Providers in Detroit, MI by specialty
• Licensed Practical Nurse in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.