Provider Demographics
NPI:1619837739
Name:BOTTOM, KHADIJAH (CHW)
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:BOTTOM
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VALENCIA DR SE APT 8
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5505
Mailing Address - Country:US
Mailing Address - Phone:575-691-9299
Mailing Address - Fax:
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5566
Practice Address - Country:US
Practice Address - Phone:505-832-7141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty