Provider Demographics
NPI:1790430361
Name:KHALIFE, DIALA
Entity Type:Individual
Prefix:
First Name:DIALA
Middle Name:
Last Name:KHALIFE
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 1:218 W MICHIGAN AVE APT C5
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8405
Mailing Address - Country:US
Mailing Address - Phone:734-272-9086
Mailing Address - Fax:
Practice Address - Street 1:4001 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3038
Practice Address - Country:US
Practice Address - Phone:313-993-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant