Provider Demographics
NPI:1801176474
Name:SUPREME WISDOM FAMILY HEALTH CLINIC INC
Entity type:Organization
Organization Name:SUPREME WISDOM FAMILY HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALILIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, APRN, BC
Authorized Official - Phone:469-835-3449
Mailing Address - Street 1:455 GOTLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2570
Mailing Address - Country:US
Mailing Address - Phone:469-831-3149
Mailing Address - Fax:
Practice Address - Street 1:455 GOTLAND DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2570
Practice Address - Country:US
Practice Address - Phone:469-831-3149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX682811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty