Provider Demographics
NPI:1497581425
Name:SMITH, MICHELLE NAKYSHIA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NAKYSHIA
Last Name:SMITH
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 1:19638 SHIELDS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2061
Mailing Address - Country:US
Mailing Address - Phone:313-452-8362
Mailing Address - Fax:
Practice Address - Street 1:19638 SHIELDS ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2061
Practice Address - Country:US
Practice Address - Phone:313-938-8515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703127811164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse