Provider Demographics
NPI:1639249931
Name:NANA, EDEWOR SPLENDID (PT)
Entity Type:Individual
Prefix:
First Name:EDEWOR
Middle Name:SPLENDID
Last Name:NANA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 NORTHLAND PARK CT STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4324
Mailing Address - Country:US
Mailing Address - Phone:313-388-7110
Mailing Address - Fax:313-388-7424
Practice Address - Street 1:17500 NORTHLAND PARK CT STE 1
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4324
Practice Address - Country:US
Practice Address - Phone:313-388-7110
Practice Address - Fax:313-388-7424
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
383588707OtherPPONN
MI4297616Medicaid
P112871OtherBCBS