Provider Demographics
NPI:1265817019
Name:WADE, NAKEYA
Entity Type:Individual
Prefix:
First Name:NAKEYA
Middle Name:
Last Name:WADE
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 1:6223 N CANTON CENTER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2696
Mailing Address - Country:US
Mailing Address - Phone:734-844-6533
Mailing Address - Fax:734-667-5079
Practice Address - Street 1:6223 N CANTON CENTER RD STE 201
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2696
Practice Address - Country:US
Practice Address - Phone:734-844-6533
Practice Address - Fax:734-667-5079
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286943163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4360685Medicaid