Healthcare Provider Details

I. General information

NPI: 1891327821
Provider Name (Legal Business Name): SAMARA BIBI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

2456 NORTHWOOD STREET
WINDSOR ONTARIO
N9E 4N7
CA

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number4704348099
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: