Provider Demographics
NPI:1265012637
Name:COLEMAN, KENYETTA MYSHAWN (ADMINISTRATOR)
Entity Type:Individual
Prefix:MS
First Name:KENYETTA
Middle Name:MYSHAWN
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:KENYETTA
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16087 MEADOWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4739
Mailing Address - Country:US
Mailing Address - Phone:248-467-1142
Mailing Address - Fax:
Practice Address - Street 1:16087 MEADOWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4739
Practice Address - Country:US
Practice Address - Phone:248-467-1142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630405536171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000000000Medicaid