Provider Demographics
NPI:1487404851
Name:MACIEL, SHAWNA ANN
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:ANN
Last Name:MACIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:ANN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1051 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5231
Mailing Address - Country:US
Mailing Address - Phone:616-795-3598
Mailing Address - Fax:616-298-2890
Practice Address - Street 1:1051 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5231
Practice Address - Country:US
Practice Address - Phone:616-795-3598
Practice Address - Fax:616-298-2890
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF030396753253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency