Provider Demographics
NPI:1558017194
Name:MOUSSA, KHALEEL MOHAMMAD
Entity Type:Individual
Prefix:
First Name:KHALEEL
Middle Name:MOHAMMAD
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 AMBERTON CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5631
Mailing Address - Country:US
Mailing Address - Phone:615-521-3962
Mailing Address - Fax:
Practice Address - Street 1:412 AMBERTON CT
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-5631
Practice Address - Country:US
Practice Address - Phone:615-521-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106760021172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver