Provider Demographics
NPI:1316535800
Name:DAVIES, KHADIJAH (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:DAVIES
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200-214 20TH AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501-3720
Mailing Address - Country:US
Mailing Address - Phone:973-460-5835
Mailing Address - Fax:
Practice Address - Street 1:24-11 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3053
Practice Address - Country:US
Practice Address - Phone:973-460-5835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG023479001744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty