Provider Demographics
NPI:1114255411
Name:FATHY, MARYAM (DNP, MSN, RN, NP-C)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:FATHY
Suffix:
Gender:F
Credentials:DNP, MSN, RN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Mailing Address - Street 1:24451 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24451 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:949-424-9730
Practice Address - Fax:949-452-7599
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704259944363LP2300X
CA21935363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care