Healthcare Provider Details

I. General information

NPI: 1912474461
Provider Name (Legal Business Name): NURU KHALIQ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date: 08/21/2024
Reactivation Date: 09/04/2024

III. Provider practice location address

935B SPRING ST
PLACERVILLE CA
95667-4523
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 510-337-7950
  • Fax:
Mailing address:
  • Phone: 949-833-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN744330
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-74534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: