Provider Demographics
NPI:1336529395
Name:FONJANKWE, ROMEO
Entity Type:Individual
Prefix:
First Name:ROMEO
Middle Name:
Last Name:FONJANKWE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8485 HONEY LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4103
Mailing Address - Country:US
Mailing Address - Phone:240-224-1812
Mailing Address - Fax:
Practice Address - Street 1:8485 HONEY LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4103
Practice Address - Country:US
Practice Address - Phone:240-224-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115041164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse