Provider Demographics
NPI:1902402407
Name:SAFIYA, MARYAM NOURI (LAC)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:NOURI
Last Name:SAFIYA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 W VICTORY BLVD # 212
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1229
Mailing Address - Country:US
Mailing Address - Phone:424-345-4344
Mailing Address - Fax:
Practice Address - Street 1:4835 VAN NUYS BLVD STE 203
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2141
Practice Address - Country:US
Practice Address - Phone:424-345-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18881171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist