1639796089 NPI number — MRS. CARLY ALYSE SHAMOUN FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639796089 NPI number — MRS. CARLY ALYSE SHAMOUN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAMOUN
Provider First Name:
CARLY
Provider Middle Name:
ALYSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALDASSARRA
Provider Other First Name:
CARLY
Provider Other Middle Name:
ALYSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639796089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 FOUNTAIN PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48327-3529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-410-1256
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9640 COMMERCE RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48382-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-363-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4704314978 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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