Provider Demographics
NPI:1124605720
Name:OSANAIYE, KEMI
Entity Type:Individual
Prefix:
First Name:KEMI
Middle Name:
Last Name:OSANAIYE
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 1:4851 VENETIAN DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6669
Mailing Address - Country:US
Mailing Address - Phone:586-718-4012
Mailing Address - Fax:
Practice Address - Street 1:32605 W 12 MILE RD STE 195
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3390
Practice Address - Country:US
Practice Address - Phone:313-306-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318487363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily