Provider Demographics
NPI:1710348503
Name:RABBAN, SOODAD (FNP)
Entity Type:Individual
Prefix:
First Name:SOODAD
Middle Name:
Last Name:RABBAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:46156 WOODWARD AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-5033
Mailing Address - Country:US
Mailing Address - Phone:248-322-6747
Mailing Address - Fax:248-322-5787
Practice Address - Street 1:4600 E 14 MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4369
Practice Address - Country:US
Practice Address - Phone:586-274-3400
Practice Address - Fax:586-274-3411
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704248759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily