Provider Demographics
NPI:1588330393
Name:HENDERSON, KAMEAH DOMONIQUE (LPN)
Entity type:Individual
Prefix:
First Name:KAMEAH
Middle Name:DOMONIQUE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29398 ELDON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2830
Mailing Address - Country:US
Mailing Address - Phone:248-943-1259
Mailing Address - Fax:
Practice Address - Street 1:350 SOUTH IRWIN ROAD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:567-703-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179296164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse