Provider Demographics
NPI:1437407160
Name:KHALIL, AYESHA (RD)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:KHALIL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:200 WEST HOSPITAL DRIVE
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-3522
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:USPHS INDIAN HOSPITAL
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-3522
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1057193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1057193OtherRDA CERTIFICATION