Provider Demographics
NPI:1457079089
Name:JONES, KHALEA ELIZABETH
Entity Type:Individual
Prefix:
First Name:KHALEA
Middle Name:ELIZABETH
Last Name:JONES
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 1:296 MENLO ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5845
Mailing Address - Country:US
Mailing Address - Phone:774-223-1985
Mailing Address - Fax:
Practice Address - Street 1:296 MENLO ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5845
Practice Address - Country:US
Practice Address - Phone:774-223-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAF07221845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily