Healthcare Provider Details

I. General information

NPI: 1881353050
Provider Name (Legal Business Name): GIDEON NGUNU NJANKWI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 SOUTHFIELD RD
ALLEN PARK MI
48101-2642
US

IV. Provider business mailing address

28915 SEDGEWAY DR
ROMULUS MI
48174-3691
US

V. Phone/Fax

Practice location:
  • Phone: 313-383-7071
  • Fax:
Mailing address:
  • Phone: 173-468-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704281219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: