Provider Demographics
NPI:1912693433
Name:MTOUR, AUDREA
Entity Type:Individual
Prefix:
First Name:AUDREA
Middle Name:
Last Name:MTOUR
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 1:684 E 159TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2414
Mailing Address - Country:US
Mailing Address - Phone:234-417-6666
Mailing Address - Fax:
Practice Address - Street 1:684 E 159TH ST # 1
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2414
Practice Address - Country:US
Practice Address - Phone:234-417-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRS468560251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health