Provider Demographics
NPI:1447720669
Name:NGUNDAM, MARILYN NAH (NP -C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:NAH
Last Name:NGUNDAM
Suffix:
Gender:F
Credentials:NP -C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23155 MISSION LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-3112
Mailing Address - Country:US
Mailing Address - Phone:240-784-0206
Mailing Address - Fax:
Practice Address - Street 1:1861 E MAPLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4207
Practice Address - Country:US
Practice Address - Phone:248-246-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704312977363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704312977OtherMI STATE LICENSE