Provider Demographics
NPI:1356950547
Name:GRAY-WASHINGTON, KHADIJAH DONWELL
Entity type:Individual
Prefix:MRS
First Name:KHADIJAH
Middle Name:DONWELL
Last Name:GRAY-WASHINGTON
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 1:9420 LINDALE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4161
Mailing Address - Country:US
Mailing Address - Phone:225-442-3540
Mailing Address - Fax:
Practice Address - Street 1:9420 LINDALE AVE STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4161
Practice Address - Country:US
Practice Address - Phone:225-442-3540
Practice Address - Fax:225-442-3546
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty