Provider Demographics
NPI:1114350774
Name:THEKKEDAM, NISHA (NP)
Entity Type:Individual
Prefix:MRS
First Name:NISHA
Middle Name:
Last Name:THEKKEDAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NISHA
Other - Middle Name:
Other - Last Name:PETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2800
Mailing Address - Fax:214-645-2808
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-645-2800
Practice Address - Fax:214-645-2808
Is Sole Proprietor?:No
Enumeration Date:2013-08-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX841763363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care