Provider Demographics
NPI:1861271637
Name:KHALEGHI, SUSAN ALEXIS (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ALEXIS
Last Name:KHALEGHI
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 1:18775 PINE CONE DR
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-9224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18775 PINE CONE DR
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-9224
Practice Address - Country:US
Practice Address - Phone:360-561-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61456036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily