Provider Demographics
NPI:1376863290
Name:MIKKLINENI, NILISHA (PT)
Entity Type:Individual
Prefix:
First Name:NILISHA
Middle Name:
Last Name:MIKKLINENI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:594 MYRTLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5617
Mailing Address - Country:US
Mailing Address - Phone:408-821-7786
Mailing Address - Fax:
Practice Address - Street 1:594 MYRTLE BEACH DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5617
Practice Address - Country:US
Practice Address - Phone:408-821-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 35459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADM452ZMedicare PIN