Healthcare Provider Details

I. General information

NPI: 1891679692
Provider Name (Legal Business Name): MOHAMED MOKHTAR BENOUNNANE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 76TH ST
BROOKLYN NY
11209-3306
US

IV. Provider business mailing address

545 76TH ST
BROOKLYN NY
11209-3306
US

V. Phone/Fax

Practice location:
  • Phone: 646-549-7430
  • Fax:
Mailing address:
  • Phone: 646-549-7430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF349642
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number740886
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: