Healthcare Provider Details

I. General information

NPI: 1972276608
Provider Name (Legal Business Name): LYANNE MARIE SANTANA KHOURY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PL STE 230
BROOKLINE MA
02445-7224
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax:
Mailing address:
  • Phone: 401-273-0641
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number3015628
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD21078
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD21078
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: