Provider Demographics
NPI:1669537387
Name:KOUNLABOUTH, MARIA ELIZABETH (NP)
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:ELIZABETH
Last Name:KOUNLABOUTH
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:321 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3718
Mailing Address - Country:US
Mailing Address - Phone:978-635-8700
Mailing Address - Fax:978-635-8920
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3718
Practice Address - Country:US
Practice Address - Phone:978-635-8700
Practice Address - Fax:978-635-8920
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA236165363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0393088Medicaid
MA0393088Medicaid
MAP48589Medicare UPIN