Provider Demographics
NPI:1619734704
Name:NKEMATABONG, AKA PRODENTIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:AKA
Middle Name:PRODENTIA
Last Name:NKEMATABONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20436 NORTHLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1156
Mailing Address - Country:US
Mailing Address - Phone:313-402-6348
Mailing Address - Fax:
Practice Address - Street 1:20436 NORTHLAWN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1156
Practice Address - Country:US
Practice Address - Phone:313-402-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280238163WH0200X, 163W00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No372600000XNursing Service Related ProvidersAdult Companion