Healthcare Provider Details

I. General information

NPI: 1205773637
Provider Name (Legal Business Name): KHUSHBU SANDESARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ELIZABETH CT
LEESBURG GA
31763-5850
US

IV. Provider business mailing address

120 ELIZABETH CT
LEESBURG GA
31763-5850
US

V. Phone/Fax

Practice location:
  • Phone: 732-822-6660
  • Fax:
Mailing address:
  • Phone: 732-822-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP289795
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: