Provider Demographics
NPI:1891217873
Name:KRIKOR, MARY (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KRIKOR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36190 WALTHAM DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4502
Mailing Address - Country:US
Mailing Address - Phone:734-925-3165
Mailing Address - Fax:
Practice Address - Street 1:36190 WALTHAM DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4831
Practice Address - Country:US
Practice Address - Phone:734-925-3165
Practice Address - Fax:734-925-3165
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF0415037OtherAANP
MI4704291626OtherLARA