=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972521417
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHALILLAH S ALI NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 GOTLAND DR
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75052-2570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-831-3149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 GOTLAND DR
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75052-2570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-831-3149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SH1100X
-----------------------------------------------------
Taxonomy Name | Holistic Clinical Nurse Specialist
-----------------------------------------------------
License Number | AP113331
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 682811
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------