Provider Demographics
NPI:1740201417
Name:KHOURY, JEANINE
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:
Last Name:KHOURY
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 1:4605 MONTICELLO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-4156
Mailing Address - Country:US
Mailing Address - Phone:803-252-7001
Mailing Address - Fax:803-252-5219
Practice Address - Street 1:4605 MONTICELLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4156
Practice Address - Country:US
Practice Address - Phone:803-252-7001
Practice Address - Fax:803-252-5219
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1215363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics