Healthcare Provider Details

I. General information

NPI: 1659665370
Provider Name (Legal Business Name): ELIZABETH ABRAHAM KOYITHOT RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORD PL HENRY FORD HOSPITAL
DETROIT MI
48202-3450
US

IV. Provider business mailing address

22192 HILLSIDE DR
NORTHVILLE MI
48167-9146
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-4688
  • Fax:
Mailing address:
  • Phone: 313-952-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704258693
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704258693
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: