Healthcare Provider Details

I. General information

NPI: 1285455196
Provider Name (Legal Business Name): KHADIJA MOHAMED JEYLANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 BLUE RIDGE BLVD STE 611D
KANSAS CITY MO
64133-1723
US

IV. Provider business mailing address

4240 BLUE RIDGE BLVD STE 611D
KANSAS CITY MO
64133-1723
US

V. Phone/Fax

Practice location:
  • Phone: 952-261-2324
  • Fax:
Mailing address:
  • Phone: 952-261-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2023026641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: