MEDICARE: KHADIJAT KEJI FASOLA I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	HHA11322	DC

General Provider Information

NPI Number	:	1053796896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHADIJAT KEJI FASOLA I

Provider Business Mailing Address
First Line	:	5120 SARGENT RD NE APT 304
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20017-2832
Country	:	US
Telephone Number	:	202-696-0940
Fax Number	:

Provider Business Practice Location Address
First Line	:	5120 SARGENT RD NE APT 304
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20017-2832
Country	:	US
Telephone Number	:	202-696-0940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2015
Last Update Date	:	09/11/2023

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