Provider Demographics
NPI:1548771322
Name:ABSALOM, KHADIJAH (NP)
Entity type:Individual
Prefix:MS
First Name:KHADIJAH
Middle Name:
Last Name:ABSALOM
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 1:34 WEXFORD LN
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5229
Mailing Address - Country:US
Mailing Address - Phone:347-821-2664
Mailing Address - Fax:
Practice Address - Street 1:355 W 52ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6239
Practice Address - Country:US
Practice Address - Phone:646-754-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily