Provider Demographics
NPI:1144672403
Name:FENNICK, MYESHA (LPN)
Entity type:Individual
Prefix:
First Name:MYESHA
Middle Name:
Last Name:FENNICK
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 1:605 WEST BROCKTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3919
Mailing Address - Country:US
Mailing Address - Phone:248-825-5401
Mailing Address - Fax:
Practice Address - Street 1:605 WEST BROCKTON AVENUE
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3919
Practice Address - Country:US
Practice Address - Phone:248-825-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110153164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse