Healthcare Provider Details

I. General information

NPI: 1245937689
Provider Name (Legal Business Name): EMILY KATHLEEN MOUTOUSIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N INGALLS ST
ANN ARBOR MI
48109-2003
US

IV. Provider business mailing address

35625 ELMIRA ST
LIVONIA MI
48150-2583
US

V. Phone/Fax

Practice location:
  • Phone: 616-446-8990
  • Fax:
Mailing address:
  • Phone: 616-446-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4704307321
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704307321
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: