Provider Demographics
NPI:1346971744
Name:ADENIYI-KASSIM, ELIZABETH O
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:O
Last Name:ADENIYI-KASSIM
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 1:7086 WELLINGTON LN
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1876
Mailing Address - Country:US
Mailing Address - Phone:313-424-2165
Mailing Address - Fax:
Practice Address - Street 1:7086 WELLINGTON LN
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1876
Practice Address - Country:US
Practice Address - Phone:313-424-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601011335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program