Healthcare Provider Details

I. General information

NPI: 1013880475
Provider Name (Legal Business Name): ANANTA KHELLAWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24806 87TH AVE PH
BELLEROSE NY
11426-2032
US

IV. Provider business mailing address

24806 87TH AVE
BELLEROSE NY
11426-2032
US

V. Phone/Fax

Practice location:
  • Phone: 718-551-4638
  • Fax:
Mailing address:
  • Phone: 718-551-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF407319
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: