Provider Demographics
NPI:1790345809
Name:FAWEHINMI, KHALIFATU O
Entity Type:Individual
Prefix:
First Name:KHALIFATU
Middle Name:O
Last Name:FAWEHINMI
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 1:656 CHARANTE CT APT 104
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5198
Mailing Address - Country:US
Mailing Address - Phone:240-475-5096
Mailing Address - Fax:
Practice Address - Street 1:3298 FORT LINCOLN DR NE APT 1010
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-4342
Practice Address - Country:US
Practice Address - Phone:240-475-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLPN46835164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse