Provider Demographics
NPI:1679063606
Name:NIKAM, SHRUTI
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:NIKAM
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 1:2425 MILLWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-4562
Mailing Address - Country:US
Mailing Address - Phone:909-674-8270
Mailing Address - Fax:
Practice Address - Street 1:4660 KENMORE AVE STE 400
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-751-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052118572251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics