Provider Demographics
NPI:1659987907
Name:BUNDY, KHATIFA
Entity Type:Individual
Prefix:
First Name:KHATIFA
Middle Name:
Last Name:BUNDY
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 1:2327 W HAGERT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-4246
Mailing Address - Country:US
Mailing Address - Phone:267-736-0893
Mailing Address - Fax:
Practice Address - Street 1:2327 W HAGERT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-4246
Practice Address - Country:US
Practice Address - Phone:267-736-0893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN312123164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse