Provider Demographics
NPI:1023567716
Name:KASSAM, EMILY HERRICK (NP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:HERRICK
Last Name:KASSAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:M
Other - Last Name:HERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:503-923-6770
Mailing Address - Fax:
Practice Address - Street 1:8100 CONSTITUTION PL NE
Practice Address - Street 2:STE 400
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7644
Practice Address - Country:US
Practice Address - Phone:505-559-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008884363LA2100X
NM62644363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care