Provider Demographics
NPI:1639446289
Name:KHAN, MARYALICE ELIZABETH (RN PHN)
Entity type:Individual
Prefix:MS
First Name:MARYALICE
Middle Name:ELIZABETH
Last Name:KHAN
Suffix:
Gender:F
Credentials:RN PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KALMUS DR
Mailing Address - Street 2:SUITE K-3
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5988
Mailing Address - Country:US
Mailing Address - Phone:714-474-2918
Mailing Address - Fax:714-242-9268
Practice Address - Street 1:151 KALMUS DR
Practice Address - Street 2:SUITE K-3
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5988
Practice Address - Country:US
Practice Address - Phone:714-474-2918
Practice Address - Fax:714-242-9268
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430219163W00000X
CA55185163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health