Provider Demographics
NPI:1467837955
Name:BOYD, KHAWANDA KIM (PBT)
Entity Type:Individual
Prefix:MS
First Name:KHAWANDA
Middle Name:KIM
Last Name:BOYD
Suffix:
Gender:F
Credentials:PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 E 13TH PL
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-3733
Mailing Address - Country:US
Mailing Address - Phone:219-588-3555
Mailing Address - Fax:219-888-9880
Practice Address - Street 1:4701 E 13TH PL
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-3733
Practice Address - Country:US
Practice Address - Phone:219-588-3555
Practice Address - Fax:219-888-9880
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2021-08-20
Deactivation Date:2020-12-02
Deactivation Code:
Reactivation Date:2021-04-12
Provider Licenses
StateLicense IDTaxonomies
IN15D2212859246RP1900X
15D2212859247ZC0005X
363A00000X, 246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant