Healthcare Provider Details

I. General information

NPI: 1962334722
Provider Name (Legal Business Name): IMMACULATE BESSEM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6223 N CANTON CENTER RD
CANTON MI
48187-2696
US

IV. Provider business mailing address

8181 N WAYNE RD APT 2146
WESTLAND MI
48185-3814
US

V. Phone/Fax

Practice location:
  • Phone: 734-660-3077
  • Fax: 734-660-3077
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number47044220990
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: