Provider Demographics
NPI:1013780493
Name:NESSA, KOLSUMA
Entity Type:Individual
Prefix:
First Name:KOLSUMA
Middle Name:
Last Name:NESSA
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 1:13490 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-1755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12501 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3243
Practice Address - Country:US
Practice Address - Phone:313-518-7566
Practice Address - Fax:313-865-1582
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703123828164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse