Provider Demographics
NPI:1902516560
Name:MBITHI, DANETTE
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:MBITHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANETTE
Other - Middle Name:
Other - Last Name:GOLLADAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6719 ANNANDALE DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4043
Mailing Address - Country:US
Mailing Address - Phone:269-808-1578
Mailing Address - Fax:
Practice Address - Street 1:6719 ANNANDALE DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-4043
Practice Address - Country:US
Practice Address - Phone:269-808-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4704283082NSA2309M363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program