Provider Demographics
NPI:1124214655
Name:SALAAM, KHAYRIYYAH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:KHAYRIYYAH
Middle Name:
Last Name:SALAAM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WELLSPRING MEDICAL/MOUNT ZION URGENT CARE
Mailing Address - Street 2:2759 MOUNT ZION PARKWAY
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236
Mailing Address - Country:US
Mailing Address - Phone:678-289-8338
Mailing Address - Fax:770-603-0515
Practice Address - Street 1:WELLSPRING MEDICAL/MOUNT ZION URGENT CARE
Practice Address - Street 2:2759 MOUNT ZION PARKWAY
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:678-289-8338
Practice Address - Fax:770-603-0515
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068062363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-12143OtherBCBS OF ALABAMA
ALZ54568OtherVIVA HEALTH
AL512-10744OtherBCBS OF ALABAMA
AL217028Medicaid
AL217554Medicaid
ALA02335AOtherMEDICARE