Provider Demographics
NPI:1013401850
Name:KHALIFA, VANESSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:KHALIFA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-653-3202
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191
Practice Address - Country:US
Practice Address - Phone:702-653-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77786OtherLICENSE