Provider Demographics
NPI:1396458360
Name:MERCHANT, MAI MARDEA
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:MARDEA
Last Name:MERCHANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAI
Other - Middle Name:MARDEA
Other - Last Name:MERCHANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:1574 68TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3005
Mailing Address - Country:US
Mailing Address - Phone:701-730-3036
Mailing Address - Fax:
Practice Address - Street 1:1574 68TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-3005
Practice Address - Country:US
Practice Address - Phone:701-730-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant