Provider Demographics
NPI:1316124563
Name:KHANE, JEANNIE ELLEN (RN)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:ELLEN
Last Name:KHANE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N APACHE AVE
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3819
Mailing Address - Country:US
Mailing Address - Phone:928-288-8266
Mailing Address - Fax:928-288-8295
Practice Address - Street 1:100 COCHISE DR
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2072
Practice Address - Country:US
Practice Address - Phone:928-288-8400
Practice Address - Fax:928-288-8492
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN139915251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)