Provider Demographics
NPI:1285322685
Name:EASTMON, KISHANA
Entity type:Individual
Prefix:
First Name:KISHANA
Middle Name:
Last Name:EASTMON
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 1:20109 E 8 MILE RD
Mailing Address - Street 2:APT 30
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1689
Mailing Address - Country:US
Mailing Address - Phone:586-738-4632
Mailing Address - Fax:
Practice Address - Street 1:12010 LINWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1108
Practice Address - Country:US
Practice Address - Phone:313-865-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator