Provider Demographics
NPI:1972521417
Name:ALI, KHALILLAH S (NP)
Entity Type:Individual
Prefix:
First Name:KHALILLAH
Middle Name:S
Last Name:ALI
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 1:455 GOTLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2570
Mailing Address - Country:US
Mailing Address - Phone:469-831-3149
Mailing Address - Fax:
Practice Address - Street 1:455 GOTLAND DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2570
Practice Address - Country:US
Practice Address - Phone:469-831-3149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP113331364SH1100X
TX682811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170329003Medicaid
TX612284Medicare PIN
TXQ33446Medicare UPIN