Healthcare Provider Details

I. General information

NPI: 1275990715
Provider Name (Legal Business Name): NIKITIA BOOTH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 BOULEVARD
COLONIAL HEIGHTS VA
23834-1320
US

IV. Provider business mailing address

3524 BOULEVARD
COLONIAL HEIGHTS VA
23834-1320
US

V. Phone/Fax

Practice location:
  • Phone: 804-805-8519
  • Fax: 804-315-1017
Mailing address:
  • Phone: 804-805-8519
  • Fax: 804-315-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173183
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: