Provider Demographics
NPI:1285493700
Name:MOZAHEM, AMELIE GHASSAN
Entity type:Individual
Prefix:
First Name:AMELIE
Middle Name:GHASSAN
Last Name:MOZAHEM
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 1:1124 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1024
Mailing Address - Country:US
Mailing Address - Phone:313-713-7602
Mailing Address - Fax:
Practice Address - Street 1:1124 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1024
Practice Address - Country:US
Practice Address - Phone:313-713-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF01231370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily