Provider Demographics
NPI:1376205849
Name:HARRIS, KHADIJAH D
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:D
Last Name:HARRIS
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 1:1316 N TREMAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3840
Mailing Address - Country:US
Mailing Address - Phone:352-800-8118
Mailing Address - Fax:
Practice Address - Street 1:1316 N TREMAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3840
Practice Address - Country:US
Practice Address - Phone:352-800-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA3547393747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant