Provider Demographics
NPI:1003393695
Name:ADEGEYE, CHARMAINE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:ADEGEYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45443 PARKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2437
Mailing Address - Country:US
Mailing Address - Phone:248-795-3553
Mailing Address - Fax:
Practice Address - Street 1:25240 LAHSER RD STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2751
Practice Address - Country:US
Practice Address - Phone:248-564-1367
Practice Address - Fax:734-725-6746
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704240600363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily