Healthcare Provider Details

I. General information

NPI: 1871343723
Provider Name (Legal Business Name): LEXI AZZARA MOUKIMOU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 ENTERPRISE RD
ORANGE CITY FL
32763-8217
US

IV. Provider business mailing address

113 ASHFORD DR
WINTER SPRINGS FL
32708-4363
US

V. Phone/Fax

Practice location:
  • Phone: 800-378-7597
  • Fax:
Mailing address:
  • Phone: 407-451-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number6950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: