Healthcare Provider Details

I. General information

NPI: 1174433528
Provider Name (Legal Business Name): KENDA I KHATTAB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 AUTO CLUB DR STE 200
DEARBORN MI
48126-2619
US

IV. Provider business mailing address

5250 AUTO CLUB DR STE 200
DEARBORN MI
48126-2619
US

V. Phone/Fax

Practice location:
  • Phone: 313-203-5300
  • Fax: 313-982-9942
Mailing address:
  • Phone: 313-203-5300
  • Fax: 313-982-9942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86373030
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: