Provider Demographics
NPI:1194317297
Name:GREENE, KHADIJAH AFIYA
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:AFIYA
Last Name:GREENE
Suffix:
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 1:9012 SUMMIT CENTRE WAY APT 204
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-5957
Mailing Address - Country:US
Mailing Address - Phone:786-800-0381
Mailing Address - Fax:
Practice Address - Street 1:830 29TH ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-6219
Practice Address - Country:US
Practice Address - Phone:407-843-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30434225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant