Provider Demographics
NPI:1417429762
Name:MUWWAKKIL, KHADIJAH
Entity Type:Individual
Prefix:MS
First Name:KHADIJAH
Middle Name:
Last Name:MUWWAKKIL
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 1:14202 20TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11351-3000
Mailing Address - Country:US
Mailing Address - Phone:347-542-5658
Mailing Address - Fax:
Practice Address - Street 1:20905 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1548
Practice Address - Country:US
Practice Address - Phone:347-542-5813
Practice Address - Fax:718-445-0951
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3299096Medicaid