Healthcare Provider Details

I. General information

NPI: 1104568088
Provider Name (Legal Business Name): NABILA KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE STE 709
FORT MYERS FL
33901-5857
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3831
  • Fax: 239-343-2301
Mailing address:
  • Phone: 239-343-3831
  • Fax: 239-343-2301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS22646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: