Provider Demographics
NPI:1063284172
Name:KHAKALI, MARK JONATHAN (RN)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JONATHAN
Last Name:KHAKALI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9449 CLEMENTINE WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-3912
Mailing Address - Country:US
Mailing Address - Phone:781-941-4008
Mailing Address - Fax:
Practice Address - Street 1:9449 CLEMENTINE WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-3912
Practice Address - Country:US
Practice Address - Phone:781-941-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA846609163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse