Healthcare Provider Details

I. General information

NPI: 1760958805
Provider Name (Legal Business Name): SALLY MICHELLE MUTCH CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 MAIN ST
HOUSTON TX
77030-2351
US

IV. Provider business mailing address

1218 BLUEBONNET DR
SEABROOK TX
77586-4722
US

V. Phone/Fax

Practice location:
  • Phone: 832-826-1929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number686744
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: