Healthcare Provider Details

I. General information

NPI: 1780357442
Provider Name (Legal Business Name): NIKKI BHARUCHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 THREE FARMS AVE
NAPERVILLE IL
60540-1105
US

IV. Provider business mailing address

28262 DIEHL RD APT 318
WARRENVILLE IL
60555-3877
US

V. Phone/Fax

Practice location:
  • Phone: 732-781-6454
  • Fax:
Mailing address:
  • Phone: 732-781-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009407
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: