Healthcare Provider Details

I. General information

NPI: 1265342646
Provider Name (Legal Business Name): DEASHA LYNAE KIDD
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

1132 E MAPLE AVE
GRAND BLANC MI
48507-4108
US

IV. Provider business mailing address

1132 E MAPLE AVE
GRAND BLANC MI
48507-4108
US

V. Phone/Fax

Practice location:
  • Phone: 810-519-6433
  • Fax:
Mailing address:
  • Phone: 810-519-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: