Basic Information
| Provider Information | |||||||||
| NPI: | 1871966234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 851 TRAFALGAR CT STE 200E | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 NW 82ND AVE | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333241811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546938160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2015 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 367500000X | 20781 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | APRN9447736 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 023205600 | 05 | FL | MEDICAID |