Provider Demographics
NPI:1235693383
Name:FABODE, KEMI A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KEMI
Middle Name:A
Last Name:FABODE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51859 LILLIAN RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3125
Mailing Address - Country:US
Mailing Address - Phone:586-770-6464
Mailing Address - Fax:586-772-4089
Practice Address - Street 1:26921 KITCH ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2515
Practice Address - Country:US
Practice Address - Phone:586-770-6464
Practice Address - Fax:586-772-4089
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820385058253J00000X
MI4703099353170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No253J00000XAgenciesFoster Care Agency