Provider Demographics
NPI:1477091445
Name:AL-KHAWALDEH, AMJAD (PHD, CNS, NP)
Entity Type:Individual
Prefix:PROF
First Name:AMJAD
Middle Name:
Last Name:AL-KHAWALDEH
Suffix:
Gender:M
Credentials:PHD, CNS, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 FALLEN LEAF PL
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6713
Mailing Address - Country:US
Mailing Address - Phone:714-875-3755
Mailing Address - Fax:
Practice Address - Street 1:3390 UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3315
Practice Address - Country:US
Practice Address - Phone:951-827-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539548163W00000X
CA95006131363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95006131OtherNP LICENSE AND FURNISHING NUMBER