Healthcare Provider Details

I. General information

NPI: 1700532876
Provider Name (Legal Business Name): DEKENIA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18307 FARMINGTON RD
LIVONIA MI
48152-3253
US

IV. Provider business mailing address

18307 FARMINGTON RD
LIVONIA MI
48152-3253
US

V. Phone/Fax

Practice location:
  • Phone: 313-221-4197
  • Fax:
Mailing address:
  • Phone: 313-221-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: