Provider Demographics
NPI:1720461270
Name:FORDE, MAIMOONAH KHADIJAN
Entity Type:Individual
Prefix:MS
First Name:MAIMOONAH
Middle Name:KHADIJAN
Last Name:FORDE
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 1:1492 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-3884
Mailing Address - Country:US
Mailing Address - Phone:718-857-4740
Mailing Address - Fax:
Practice Address - Street 1:1492 BEDFORD AVE
Practice Address - Street 2:#2B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-3884
Practice Address - Country:US
Practice Address - Phone:718-857-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1792876174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist