Provider Demographics
NPI:1962702233
Name:HARRIS, KANICA
Entity type:Individual
Prefix:
First Name:KANICA
Middle Name:
Last Name:HARRIS
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 1:8449 W. PARKWAY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1157
Mailing Address - Country:US
Mailing Address - Phone:313-598-0095
Mailing Address - Fax:313-274-2835
Practice Address - Street 1:8449 W PARKWAY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48239-1157
Practice Address - Country:US
Practice Address - Phone:313-598-0095
Practice Address - Fax:313-274-2835
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker