Healthcare Provider Details

I. General information

NPI: 1689208050
Provider Name (Legal Business Name): MR. JEAN-MERIMEE KOUAGHEU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 PATTON RD
DEVENS MA
01434-4401
US

IV. Provider business mailing address

43 NORWOOD AVE
AYER MA
01432
US

V. Phone/Fax

Practice location:
  • Phone: 978-615-5200
  • Fax:
Mailing address:
  • Phone: 978-551-1607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2263506
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: