Provider Demographics
NPI:1366102378
Name:BASSALIOUS, MARIAM (DNP, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:BASSALIOUS
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36650 KENNETH CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3156
Mailing Address - Country:US
Mailing Address - Phone:248-635-2919
Mailing Address - Fax:
Practice Address - Street 1:9021 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3726
Practice Address - Country:US
Practice Address - Phone:313-871-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-19
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704344060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily