Provider Demographics
NPI:1902465891
Name:KHANAFER, MARIAM H (MSN, RN, FNP)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:H
Last Name:KHANAFER
Suffix:
Gender:F
Credentials:MSN, RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 N CHARLESWORTH ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3630
Mailing Address - Country:US
Mailing Address - Phone:313-492-5975
Mailing Address - Fax:
Practice Address - Street 1:5728 SCHAEFER RD STE 103
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2287
Practice Address - Country:US
Practice Address - Phone:313-581-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704303967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily