Provider Demographics
NPI:1679090187
Name:KHAN, JENNIFER DIANE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:KHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4341
Mailing Address - Country:US
Mailing Address - Phone:607-206-3147
Mailing Address - Fax:
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily