Healthcare Provider Details

I. General information

NPI: 1154237600
Provider Name (Legal Business Name): LARA FAWAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N INGALLS ST
ANN ARBOR MI
48109-2003
US

IV. Provider business mailing address

7023 ROSEMARY ST
DEARBORN HEIGHTS MI
48127-4608
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-5985
  • Fax:
Mailing address:
  • Phone: 313-442-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704403545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: