Healthcare Provider Details

I. General information

NPI: 1194131649
Provider Name (Legal Business Name): AMI KHASAKIA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 DOUGLAS BLVD
ROSEVILLE CA
95661-3866
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-8300
  • Fax: 916-774-8327
Mailing address:
  • Phone: 800-972-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: