Provider Demographics
NPI:1235735358
Name:RIDDICK, KHADIJAH
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SOUTH ST STE A
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-1948
Mailing Address - Country:US
Mailing Address - Phone:757-304-5390
Mailing Address - Fax:
Practice Address - Street 1:701 SOUTH ST STE A
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1948
Practice Address - Country:US
Practice Address - Phone:757-304-5390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health