Provider Demographics
NPI:1265456388
Name:WADDELL, NIKKI (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKKI
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:5901 KINGSTOWNE VILLAGE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5880
Practice Address - Country:US
Practice Address - Phone:571-384-6304
Practice Address - Fax:571-384-6309
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239628207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC233305ZBTPMedicare PIN