Provider Demographics
NPI:1881824050
Name:OSBOURNE, KHADIJAH A (RN)
Entity Type:Individual
Prefix:MRS
First Name:KHADIJAH
Middle Name:A
Last Name:OSBOURNE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-3328
Mailing Address - Country:US
Mailing Address - Phone:315-863-0107
Mailing Address - Fax:
Practice Address - Street 1:1856 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-3328
Practice Address - Country:US
Practice Address - Phone:315-863-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY611512163W00000X
NY236334164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse