Provider Demographics
NPI:1871307629
Name:MANSOUR, KARENNA RAJA
Entity type:Individual
Prefix:
First Name:KARENNA
Middle Name:RAJA
Last Name:MANSOUR
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 1:2331 GOLDEN POND
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1098
Mailing Address - Country:US
Mailing Address - Phone:810-922-5928
Mailing Address - Fax:
Practice Address - Street 1:17320 W 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2102
Practice Address - Country:US
Practice Address - Phone:248-727-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program