Provider Demographics
NPI:1013794544
Name:KHALIFA, SOPHIA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KHALIFA
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 1:5 WEBBER RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-2838
Mailing Address - Country:US
Mailing Address - Phone:617-771-8718
Mailing Address - Fax:
Practice Address - Street 1:85 PATTON RD
Practice Address - Street 2:
Practice Address - City:DEVENS
Practice Address - State:MA
Practice Address - Zip Code:01434-4401
Practice Address - Country:US
Practice Address - Phone:978-615-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311715363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health