Provider Demographics
NPI:1669015764
Name:BHAKTA, NISHA
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:BHAKTA
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 1:5025 E HIGHWAY 82
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6070
Mailing Address - Country:US
Mailing Address - Phone:662-378-7437
Mailing Address - Fax:
Practice Address - Street 1:1257 HIGHWAY 61 S
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3864
Practice Address - Country:US
Practice Address - Phone:662-827-2214
Practice Address - Fax:662-827-2215
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903573363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner