Healthcare Provider Details

I. General information

NPI: 1396609715
Provider Name (Legal Business Name): KATRINA DAISY MANSOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 04/05/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 W BRISTOL RD STE 150
FLINT MI
48507-3161
US

IV. Provider business mailing address

4444 W BRISTOL RD STE 150
FLINT MI
48507-3161
US

V. Phone/Fax

Practice location:
  • Phone: 833-322-3376
  • Fax: 248-607-6777
Mailing address:
  • Phone: 833-322-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: