Provider Demographics
NPI:1265612725
Name:KHADAR, FATIMA (NP)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:KHADAR
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 1:1070 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5709
Mailing Address - Country:US
Mailing Address - Phone:401-455-3574
Mailing Address - Fax:401-455-3624
Practice Address - Street 1:1070 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5709
Practice Address - Country:US
Practice Address - Phone:401-454-3574
Practice Address - Fax:401-455-3624
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP 37444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner