Provider Demographics
NPI:1629445291
Name:SANDERS, CHARISSE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:
Last Name:SANDERS
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 1:9000 E JEFFERSON AVE
Mailing Address - Street 2:11-14
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-4188
Mailing Address - Country:US
Mailing Address - Phone:313-850-3654
Mailing Address - Fax:
Practice Address - Street 1:9000 E JEFFERSON AVE
Practice Address - Street 2:11-14
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-4188
Practice Address - Country:US
Practice Address - Phone:313-850-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-30
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7379352Medicaid