Healthcare Provider Details

I. General information

NPI: 1467837955
Provider Name (Legal Business Name): KHAWANDA KIM BOYD PBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 08/20/2021
Certification Date: 08/01/2021
Deactivation Date: 12/02/2020
Reactivation Date: 04/12/2021

III. Provider practice location address

4701 E 13TH PL
GARY IN
46403-3733
US

IV. Provider business mailing address

4701 E 13TH PL
GARY IN
46403-3733
US

V. Phone/Fax

Practice location:
  • Phone: 219-588-3555
  • Fax: 219-888-9880
Mailing address:
  • Phone: 219-588-3555
  • Fax: 219-888-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number15D2212859
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number15D2212859
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: