Provider Demographics
NPI:1477250223
Name:KNIGHT, JULISSA AGUSTINA
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:AGUSTINA
Last Name:KNIGHT
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 1:626 GREENE CT
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-4424
Mailing Address - Country:US
Mailing Address - Phone:917-755-9665
Mailing Address - Fax:
Practice Address - Street 1:626 GREENE CT
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-4424
Practice Address - Country:US
Practice Address - Phone:917-755-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA59203601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty