Provider Demographics
NPI:1578333407
Name:DAVEY-FORTSON, MAREKA
Entity Type:Individual
Prefix:
First Name:MAREKA
Middle Name:
Last Name:DAVEY-FORTSON
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 1:3600 14TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2685
Mailing Address - Country:US
Mailing Address - Phone:313-296-6155
Mailing Address - Fax:
Practice Address - Street 1:3600 14TH ST APT 202
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2685
Practice Address - Country:US
Practice Address - Phone:313-296-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230015552120811376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty