Provider Demographics
NPI:1932661170
Name:MOHIUDDIN, KHAIRUNISSA BATOOL (NP)
Entity Type:Individual
Prefix:
First Name:KHAIRUNISSA
Middle Name:BATOOL
Last Name:MOHIUDDIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-540-3387
Mailing Address - Fax:502-540-3393
Practice Address - Street 1:4423 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-495-2400
Practice Address - Fax:502-495-6345
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily