Basic Information
| Provider Information | |||||||||
| NPI: | 1437407160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHALIL | ||||||||
| FirstName: | AYESHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | 200 WEST HOSPITAL DRIVE | ||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283383522 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
| Address2: | USPHS INDIAN HOSPITAL | ||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283383522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 07/31/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1057193 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1057193 | 01 | RDA CERTIFICATION | OTHER |