Provider Demographics
NPI:1437692142
Name:KHATIBIJAH, LADAN
Entity Type:Individual
Prefix:
First Name:LADAN
Middle Name:
Last Name:KHATIBIJAH
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 1:1660 E ROSEVILLE PKWY BLDG 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3988
Mailing Address - Country:US
Mailing Address - Phone:916-973-5300
Mailing Address - Fax:
Practice Address - Street 1:1660 E ROSEVILLE PKWY BLDG 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-973-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program