Provider Demographics
NPI:1003563636
Name:MOUZON, PHENITA SAMMANTHA
Entity Type:Individual
Prefix:
First Name:PHENITA
Middle Name:SAMMANTHA
Last Name:MOUZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 WOODHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2062
Mailing Address - Country:US
Mailing Address - Phone:732-998-7191
Mailing Address - Fax:
Practice Address - Street 1:777 ROUTE 70 E STE G101
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2548
Practice Address - Country:US
Practice Address - Phone:856-818-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01281000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health