=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679063606
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHRUTI NIKAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 08/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4660 KENMORE AVE STE 400
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-751-1008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2425 MILLWOOD LOOP
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22801-4562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-674-8270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number | 2305211857
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------