Provider Demographics
NPI:1740447127
Name:KHALIFA, MISTY MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MARIE
Last Name:KHALIFA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:MISTY
Other - Middle Name:MARIE
Other - Last Name:FALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1930 KOEFOOT DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-3279
Mailing Address - Country:US
Mailing Address - Phone:317-390-4699
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-988-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28174424A163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine