=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225548324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIVAKSHA KHANDURI DNP, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2017
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7631 212TH ST SW STE 107B
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98026-7565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-610-9394
-----------------------------------------------------
Fax | 833-418-1959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4580 KLAHANIE DR SE # 197
-----------------------------------------------------
City | SAMMAMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98029-5812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-610-9394
-----------------------------------------------------
Fax | 833-418-1959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP60798086
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------