Provider Demographics
NPI:1568055275
Name:KASED, NIDA
Entity Type:Individual
Prefix:
First Name:NIDA
Middle Name:
Last Name:KASED
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 1:21123 DUNS SCOTUS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19850 M GIBRALTAR RD
Practice Address - Street 2:
Practice Address - City:GIBRALTAR
Practice Address - State:MI
Practice Address - Zip Code:48173-8701
Practice Address - Country:US
Practice Address - Phone:734-301-3125
Practice Address - Fax:734-301-3325
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1020387133V00000X
MI4704350057163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704350057OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
MI1020387OtherCOMMISSION ON DIETETIC REGISTRATION