Provider Demographics
NPI:1831704410
Name:KHAN, ELIZAH D (LMT)
Entity type:Individual
Prefix:
First Name:ELIZAH
Middle Name:D
Last Name:KHAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ELIZAH
Other - Middle Name:DEANA
Other - Last Name:WYNNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23411 SUMMERFIELD APT 48C
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2836
Mailing Address - Country:US
Mailing Address - Phone:985-217-4889
Mailing Address - Fax:
Practice Address - Street 1:23411 SUMMERFIELD APT 48C
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-2836
Practice Address - Country:US
Practice Address - Phone:985-217-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73379225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist