Healthcare Provider Details

I. General information

NPI: 1205743168
Provider Name (Legal Business Name): CENIQUE YELDELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 VILLAGE PARK DR
WEST BLOOMFIELD MI
48322-2153
US

IV. Provider business mailing address

6313 VILLAGE PARK DR
WEST BLOOMFIELD MI
48322-2153
US

V. Phone/Fax

Practice location:
  • Phone: 248-747-1099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: