Provider Demographics
NPI:1700247772
Name:BOGGON, KAMERA SAKEENA (AGNP -C)
Entity Type:Individual
Prefix:
First Name:KAMERA
Middle Name:SAKEENA
Last Name:BOGGON
Suffix:
Gender:F
Credentials:AGNP -C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15662 MOUNT VERNON
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:313-478-6204
Mailing Address - Fax:
Practice Address - Street 1:39465 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1600
Practice Address - Country:US
Practice Address - Phone:248-859-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248431363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health