Basic Information
| Provider Information | |||||||||
| NPI: | 1083106140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KASSA | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 GRACE AVUENUE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482272897 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N PERRY ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483422217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483385645 | ||||||||
| FaxNumber: | 2483385547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 4704297338 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.