Provider Demographics
NPI:1093868507
Name:MOURTZINOS, STEPHANIE ATHANASOULAS (NP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ATHANASOULAS
Last Name:MOURTZINOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LCHC
Mailing Address - Street 2:585 - 597 MERRIMACK STREET
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-322-8500
Mailing Address - Fax:
Practice Address - Street 1:LCHC
Practice Address - Street 2:17 WARREN STREET, 2ND FLOOR
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-322-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230081163WD0400X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily