Healthcare Provider Details

I. General information

NPI: 1639787567
Provider Name (Legal Business Name): ISHA KHALIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 CRAIN ST
SKOKIE IL
60077-2147
US

IV. Provider business mailing address

5242 CRAIN ST
SKOKIE IL
60077-2147
US

V. Phone/Fax

Practice location:
  • Phone: 847-904-3319
  • Fax:
Mailing address:
  • Phone: 847-904-3319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: