Provider Demographics
NPI:1457088247
Name:FATHI, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:FATHI
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 1:7320 WOODLAKE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1471
Mailing Address - Country:US
Mailing Address - Phone:818-346-9911
Mailing Address - Fax:
Practice Address - Street 1:7320 WOODLAKE AVE STE 310
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1471
Practice Address - Country:US
Practice Address - Phone:818-346-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022154363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty