MEDICARE: NELLI KHALLAK NP

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	363LF0000X	Family Nurse Practitioner	71004630A	IN

General Provider Information

NPI Number	:	1871922740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELLI KHALLAK NP

Provider Business Mailing Address
First Line	:	2241 45TH ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-2601
Country	:	US
Telephone Number	:	219-922-8051
Fax Number	:	219-922-8608

Provider Business Practice Location Address
First Line	:	2241 45TH ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-2601
Country	:	US
Telephone Number	:	219-922-8051
Fax Number	:	219-922-8608

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

Provider Enumeration Date	:	11/01/2013
Last Update Date	:	11/01/2013

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Directions to “ NELLI KHALLAK NP” Practice Location

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