Healthcare Provider Details

I. General information

NPI: 1619515442
Provider Name (Legal Business Name): NIKITTA DHILLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 CEDAR LN
COLUMBIA MD
21044-2912
US

IV. Provider business mailing address

45728 LARCHMONT DR
CANTON MI
48187-4717
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-7825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC07429
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: