Provider Demographics
NPI:1841042751
Name:COON, KADEJAH DORENA
Entity type:Individual
Prefix:MRS
First Name:KADEJAH
Middle Name:DORENA
Last Name:COON
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 1:5260 IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-3632
Mailing Address - Country:US
Mailing Address - Phone:313-407-2088
Mailing Address - Fax:
Practice Address - Street 1:5260 IVANHOE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-3632
Practice Address - Country:US
Practice Address - Phone:313-407-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty