Provider Demographics
NPI:1023763828
Name:FAWAZ, VICTORIA KATHLEEN HELEN (NP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:KATHLEEN HELEN
Last Name:FAWAZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:KATHLEEN HELEN
Other - Last Name:ZIRALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37150 MALLORY DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1175
Mailing Address - Country:US
Mailing Address - Phone:313-588-1988
Mailing Address - Fax:
Practice Address - Street 1:159 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3610
Practice Address - Country:US
Practice Address - Phone:313-640-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295277NSA200VH363LF0000X
MI4704295277363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily