Healthcare Provider Details

I. General information

NPI: 1528921624
Provider Name (Legal Business Name): KOFFI BLEWOUSSI AZIANKOU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HORSE TRAIL LN
FELTON DE
19943-6648
US

IV. Provider business mailing address

120 HORSE TRAIL LN
FELTON DE
19943-6648
US

V. Phone/Fax

Practice location:
  • Phone: 732-598-9600
  • Fax:
Mailing address:
  • Phone: 732-598-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberU2-0012311
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: