Provider Demographics
NPI:1235751421
Name:NIKZAD, AMENEH
Entity Type:Individual
Prefix:MRS
First Name:AMENEH
Middle Name:
Last Name:NIKZAD
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:TAGHI
Other - Middle Name:DEHGHAN
Other - Last Name:DEHNAVI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DENIKVR MANAGMENT
Mailing Address - Street 1:132 PLAYA CIR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1627
Mailing Address - Country:US
Mailing Address - Phone:949-922-1849
Mailing Address - Fax:
Practice Address - Street 1:132 PLAYA CIR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-1627
Practice Address - Country:US
Practice Address - Phone:949-922-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5122222172A00000X
CAA2540781172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver