Healthcare Provider Details

I. General information

NPI: 1629557764
Provider Name (Legal Business Name): ALLISON PHALLIME HUOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 12/22/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LAWNDALE RD
TYNGSBORO MA
01879-1520
US

IV. Provider business mailing address

10 LAWNDALE RD
TYNGSBORO MA
01879-1520
US

V. Phone/Fax

Practice location:
  • Phone: 978-761-4008
  • Fax:
Mailing address:
  • Phone: 978-761-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6684
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: