Provider Demographics
NPI:1396400164
Name:NIDA, KODI
Entity Type:Individual
Prefix:
First Name:KODI
Middle Name:
Last Name:NIDA
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 1:1544 OLD WOLF CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NARROWS
Mailing Address - State:VA
Mailing Address - Zip Code:24124-2531
Mailing Address - Country:US
Mailing Address - Phone:304-994-1009
Mailing Address - Fax:
Practice Address - Street 1:1544 OLD WOLF CREEK RD
Practice Address - Street 2:
Practice Address - City:NARROWS
Practice Address - State:VA
Practice Address - Zip Code:24124-2531
Practice Address - Country:US
Practice Address - Phone:304-994-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant