Healthcare Provider Details

I. General information

NPI: 1043238033
Provider Name (Legal Business Name): JAN CARLIN KHOURI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-703-6400
  • Fax:
Mailing address:
  • Phone: 360-353-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00096700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: