Provider Demographics
NPI:1447790043
Name:CHAMMOUT, MIKE (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:CHAMMOUT
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21021 ERWIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3828
Mailing Address - Country:US
Mailing Address - Phone:313-525-6575
Mailing Address - Fax:
Practice Address - Street 1:22950 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2500
Practice Address - Country:US
Practice Address - Phone:818-887-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287221363LF0000X
CA95010167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily