Provider Demographics
NPI:1245605658
Name:KHOSRAVI, AZADEH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:AZADEH
Middle Name:
Last Name:KHOSRAVI
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 1:5590 JANET BLVD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1961
Mailing Address - Country:US
Mailing Address - Phone:330-766-2700
Mailing Address - Fax:
Practice Address - Street 1:3999 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6046
Practice Address - Country:US
Practice Address - Phone:330-766-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18069.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily