Provider Demographics
NPI:1962097717
Name:WORTHAM, KYESHA NICOLE (CNA)
Entity type:Individual
Prefix:MRS
First Name:KYESHA
Middle Name:NICOLE
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14218 BRAILE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2720
Mailing Address - Country:US
Mailing Address - Phone:313-404-8244
Mailing Address - Fax:
Practice Address - Street 1:14218 BRAILE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2720
Practice Address - Country:US
Practice Address - Phone:313-404-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230012659100806374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty