Healthcare Provider Details

I. General information

NPI: 1528736360
Provider Name (Legal Business Name): LILYNE MICHELE MEKOUDJOU TCHAKONTE NURSE PRACTITONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10899 SW 4TH ST APT 601
MIAMI FL
33174-4402
US

IV. Provider business mailing address

3838 N CAMPBELL AVE
TUCSON AZ
85719-1454
US

V. Phone/Fax

Practice location:
  • Phone: 404-740-0112
  • Fax:
Mailing address:
  • Phone: 404-740-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: