Provider Demographics
NPI:1710517602
Name:ROBINSON, KOINONIA
Entity Type:Individual
Prefix:MRS
First Name:KOINONIA
Middle Name:
Last Name:ROBINSON
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 1:11830 BEACONSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-4107
Mailing Address - Country:US
Mailing Address - Phone:313-454-6676
Mailing Address - Fax:
Practice Address - Street 1:4875 COPLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2192
Practice Address - Country:US
Practice Address - Phone:313-822-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3134546676Medicaid