Provider Demographics
NPI:1073342325
Name:KENAN, DETAVIA (CMA)
Entity type:Individual
Prefix:
First Name:DETAVIA
Middle Name:
Last Name:KENAN
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WHISTLING SWAN DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-1535
Mailing Address - Country:US
Mailing Address - Phone:919-696-6125
Mailing Address - Fax:
Practice Address - Street 1:2 CENTERVIEW DR STE 64
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3708
Practice Address - Country:US
Practice Address - Phone:336-303-0587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No253Z00000XAgenciesIn Home Supportive Care