Healthcare Provider Details

I. General information

NPI: 1639796089
Provider Name (Legal Business Name): CARLY ALYSE SHAMOUN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARLY ALYSE BALDASSARRA FNP-C

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 08/09/2023
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 COMMERCE RD STE 104
COMMERCE TOWNSHIP MI
48382-4167
US

IV. Provider business mailing address

210 FOUNTAIN PARK DR
WATERFORD MI
48327-3529
US

V. Phone/Fax

Practice location:
  • Phone: 248-363-1500
  • Fax:
Mailing address:
  • Phone: 248-410-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704314978
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: