Provider Demographics
NPI:1194468801
Name:COLLEY, KENERA (DO)
Entity type:Individual
Prefix:DR
First Name:KENERA
Middle Name:
Last Name:COLLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:361-902-4789
Mailing Address - Fax:
Practice Address - Street 1:3370 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4236
Practice Address - Country:US
Practice Address - Phone:313-656-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10078798390200000X
MI5101028735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program