Provider Demographics
NPI:1679169163
Name:KEJBOU, SALLY WARDA (AGNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:WARDA
Last Name:KEJBOU
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-3453
Mailing Address - Country:US
Mailing Address - Phone:248-298-9549
Mailing Address - Fax:
Practice Address - Street 1:615 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3453
Practice Address - Country:US
Practice Address - Phone:248-298-9549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327329363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology