Provider Demographics
NPI:1396208955
Name:KHOSHABA, MANUELLA D
Entity type:Individual
Prefix:
First Name:MANUELLA
Middle Name:D
Last Name:KHOSHABA
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 1:7201 W CAMINO SAN XAVIER
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3798
Mailing Address - Country:US
Mailing Address - Phone:623-703-2748
Mailing Address - Fax:
Practice Address - Street 1:7201 W CAMINO SAN XAVIER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3798
Practice Address - Country:US
Practice Address - Phone:623-703-2748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013818314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility