Provider Demographics
NPI:1851834824
Name:FENDERSON, ALETHEA (RN)
Entity Type:Individual
Prefix:
First Name:ALETHEA
Middle Name:
Last Name:FENDERSON
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 1:19352 MARX ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203
Mailing Address - Country:US
Mailing Address - Phone:313-399-0611
Mailing Address - Fax:
Practice Address - Street 1:19352 MARX ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1338
Practice Address - Country:US
Practice Address - Phone:313-399-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703116076164W00000X
MI4704397418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse