Healthcare Provider Details

I. General information

NPI: 1497574610
Provider Name (Legal Business Name): MIKAYLAH MARIE CLOUTIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N 16TH ST STE 102
PHOENIX AZ
85020
US

IV. Provider business mailing address

2624 W 44TH AVE
DENVER CO
80211-1447
US

V. Phone/Fax

Practice location:
  • Phone: 623-233-0914
  • Fax:
Mailing address:
  • Phone: 207-592-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1000275-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number316403
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: