Healthcare Provider Details

I. General information

NPI: 1184516320
Provider Name (Legal Business Name): OCTAVIA BRONAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8623 N WAYNE RD STE 104
WESTLAND MI
48185-1137
US

IV. Provider business mailing address

1231 NORTHWOOD DR
INKSTER MI
48141-1770
US

V. Phone/Fax

Practice location:
  • Phone: 734-425-0636
  • Fax:
Mailing address:
  • Phone: 313-283-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: