Healthcare Provider Details

I. General information

NPI: 1023743986
Provider Name (Legal Business Name): LEENAH HISHAM A KHAYAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

IV. Provider business mailing address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95012801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: