Provider Demographics
NPI:1295912624
Name:MUSALLAM, BETHANY ANNE (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ANNE
Last Name:MUSALLAM
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:ANNE
Other - Last Name:HAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15125 22 MILE RD.
Mailing Address - Street 2:SHELBY PEDIATRICS
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315
Mailing Address - Country:US
Mailing Address - Phone:586-532-0599
Mailing Address - Fax:586-566-8967
Practice Address - Street 1:15125 22 MILE RD.
Practice Address - Street 2:SHELBY PEDIATRICS
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-532-0599
Practice Address - Fax:586-566-8967
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244961363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120130Medicare PIN