Healthcare Provider Details

I. General information

NPI: 1457262784
Provider Name (Legal Business Name): MRS. KORYNE IRENE KOUTOUVIDES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 POST RD STE 203
FAIRFIELD CT
06824-6072
US

IV. Provider business mailing address

750 VERNA HILL RD
FAIRFIELD CT
06824-2057
US

V. Phone/Fax

Practice location:
  • Phone: 860-922-6447
  • Fax:
Mailing address:
  • Phone: 860-922-6447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number2154
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: