Provider Demographics
NPI:1922726389
Name:KING, HANEEFAH (AESTHETICIAN)
Entity Type:Individual
Prefix:
First Name:HANEEFAH
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:AESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 WINNETKA AVE N STE 210
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2866
Mailing Address - Country:US
Mailing Address - Phone:612-281-8989
Mailing Address - Fax:
Practice Address - Street 1:2960 WINNETKA AVE N STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55427-2866
Practice Address - Country:US
Practice Address - Phone:612-281-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21040330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty