Provider Demographics
NPI:1780213199
Name:RAHMANI, MARYAM KHALILY
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:KHALILY
Last Name:RAHMANI
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:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-2048
Mailing Address - Country:US
Mailing Address - Phone:409-718-8084
Mailing Address - Fax:
Practice Address - Street 1:8595 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2428
Practice Address - Country:US
Practice Address - Phone:409-721-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily