Healthcare Provider Details

I. General information

NPI: 1457805475
Provider Name (Legal Business Name): SALOUA MABKHOUTI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MAIN ST N
WOODBURY CT
06798-2966
US

IV. Provider business mailing address

1625 STRAITS TPKE SUITE 201
MIDDLEBURY CT
06762-1836
US

V. Phone/Fax

Practice location:
  • Phone: 203-266-0080
  • Fax: 203-575-5221
Mailing address:
  • Phone: 320-357-3951
  • Fax: 320-357-5520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number006607
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: