Provider Demographics
NPI:1538542725
Name:SNODDERLY, LENIA KAY
Entity type:Individual
Prefix:MISS
First Name:LENIA
Middle Name:KAY
Last Name:SNODDERLY
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 1:11109 CELIA RD
Mailing Address - Street 2:
Mailing Address - City:CARLETON
Mailing Address - State:MI
Mailing Address - Zip Code:48117-9314
Mailing Address - Country:US
Mailing Address - Phone:734-512-6090
Mailing Address - Fax:
Practice Address - Street 1:12168 CHURCHILL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2392
Practice Address - Country:US
Practice Address - Phone:313-316-0428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5317172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5317OtherDOMUS VITA