Healthcare Provider Details

I. General information

NPI: 1194330258
Provider Name (Legal Business Name): LOVELYN C OGBENNAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26677 W 12 MILE RD STE 166
SOUTHFIELD MI
48034-1514
US

IV. Provider business mailing address

7444 CAMELOT DR
WEST BLOOMFIELD MI
48322-3133
US

V. Phone/Fax

Practice location:
  • Phone: 313-306-2023
  • Fax:
Mailing address:
  • Phone: 313-478-8902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704232390
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: