Provider Demographics
NPI:1053796896
Name:FASOLA, KHADIJAT KEJI I
Entity type:Individual
Prefix:
First Name:KHADIJAT
Middle Name:KEJI
Last Name:FASOLA
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 SARGENT RD NE APT 304
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2832
Mailing Address - Country:US
Mailing Address - Phone:202-696-0940
Mailing Address - Fax:
Practice Address - Street 1:5120 SARGENT RD NE APT 304
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2832
Practice Address - Country:US
Practice Address - Phone:202-696-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11322374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide