Provider Demographics
NPI:1326821836
Name:TARAWALLY, KHADIJAH ADAMA
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:ADAMA
Last Name:TARAWALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 MASTERS LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3583
Mailing Address - Country:US
Mailing Address - Phone:140-437-5915
Mailing Address - Fax:
Practice Address - Street 1:2151 PEACHFORD RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6599
Practice Address - Country:US
Practice Address - Phone:770-455-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN262730363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health