Provider Demographics
NPI:1932240603
Name:KHULUSI, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KHULUSI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 STATE ROUTE 35 S
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1876
Mailing Address - Country:US
Mailing Address - Phone:732-389-5004
Mailing Address - Fax:732-389-1850
Practice Address - Street 1:142 STATE ROUTE 35 S
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1876
Practice Address - Country:US
Practice Address - Phone:732-389-5004
Practice Address - Fax:732-389-1850
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00061500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ40763Medicare UPIN
NJ089727Medicare ID - Type Unspecified