Healthcare Provider Details

I. General information

NPI: 1093628703
Provider Name (Legal Business Name): SOKHNA MAMEBOUSSO N'DOUR
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2464 FORTUNE DR
LEXINGTON KY
40509-4260
US

IV. Provider business mailing address

456 PARK AVE
LEXINGTON KY
40502-2139
US

V. Phone/Fax

Practice location:
  • Phone: 859-899-9200
  • Fax:
Mailing address:
  • Phone: 859-787-9745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: