Provider Demographics
NPI:1245723212
Name:EDMONDSON, KHALILAH
Entity type:Individual
Prefix:
First Name:KHALILAH
Middle Name:
Last Name:EDMONDSON
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 1:20110 CHERRYLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1105
Mailing Address - Country:US
Mailing Address - Phone:313-409-0469
Mailing Address - Fax:
Practice Address - Street 1:13930 FORRER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-1741
Practice Address - Country:US
Practice Address - Phone:248-716-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703106296164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse