Provider Demographics
NPI:1639796089
Name:SHAMOUN, CARLY ALYSE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:ALYSE
Last Name:SHAMOUN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ALYSE
Other - Last Name:BALDASSARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:210 FOUNTAIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-3529
Mailing Address - Country:US
Mailing Address - Phone:248-410-1256
Mailing Address - Fax:
Practice Address - Street 1:9640 COMMERCE RD STE 104
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-4167
Practice Address - Country:US
Practice Address - Phone:248-363-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily