Healthcare Provider Details

I. General information

NPI: 1477091445
Provider Name (Legal Business Name): AMJAD AL-KHAWALDEH PHD, CNS, NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24953 PASEO DE VALENCIA STE 24A
LAGUNA HILLS CA
92653-4343
US

IV. Provider business mailing address

2012 FALLEN LEAF PL
TUSTIN CA
92780-6713
US

V. Phone/Fax

Practice location:
  • Phone: 714-875-3755
  • Fax:
Mailing address:
  • Phone: 714-875-3755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: