Provider Demographics
NPI:1548509912
Name:LOVENCE, KEISHA TAMARA (NP-C)
Entity type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:TAMARA
Last Name:LOVENCE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:TAMARA
Other - Last Name:LOVENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NPC
Mailing Address - Street 1:630 MERRICK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3950
Mailing Address - Country:US
Mailing Address - Phone:313-854-8838
Mailing Address - Fax:
Practice Address - Street 1:15101 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3716
Practice Address - Country:US
Practice Address - Phone:313-838-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704264763363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care