Healthcare Provider Details

I. General information

NPI: 1124779764
Provider Name (Legal Business Name): AWAZ KHOSHNAW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 CAMINITO CLAVO
SAN DIEGO CA
92120-3037
US

IV. Provider business mailing address

6109 CAMINITO CLAVO
SAN DIEGO CA
92120-3037
US

V. Phone/Fax

Practice location:
  • Phone: 619-813-6325
  • Fax:
Mailing address:
  • Phone: 619-813-6325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95244421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: