Healthcare Provider Details

I. General information

NPI: 1972076693
Provider Name (Legal Business Name): KAODICHINMA OGBONNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

18362 CEDAR ISLAND BLVD
BROWNSTOWN MI
48174-9584
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-1400
  • Fax:
Mailing address:
  • Phone: 313-646-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704267833
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: