Provider Demographics
NPI:1558985564
Name:FARAJ, KATHRYN (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:FARAJ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E HARRY AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2055
Mailing Address - Country:US
Mailing Address - Phone:248-850-0263
Mailing Address - Fax:
Practice Address - Street 1:344 E HARRY AVE
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-2055
Practice Address - Country:US
Practice Address - Phone:248-850-0263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311216363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner