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General NPI Number Information
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NPI Number | 1871307629
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Entity Type | Individual
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Provider Name | KARENNA RAJA MANSOUR
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Gender | Female
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Dates
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Enumeration Date | 02/03/2025
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Last Update Date | 02/03/2025
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Provider Practice Location Address
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Address Line | 17320 W 12 MILE RD STE 101
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City | SOUTHFIELD
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State | MI
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Zip | 48076-2102
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Country | US
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Telephone | 248-727-3456
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Fax |
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Provider Business Mailing Address
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Address Line | 2331 GOLDEN POND
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City | FENTON
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State | MI
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Zip | 48430-1098
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Country | US
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Telephone | 810-922-5928
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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