Provider Demographics
NPI:1689138141
Name:NAMBOODIRI, INDI
Entity Type:Individual
Prefix:
First Name:INDI
Middle Name:
Last Name:NAMBOODIRI
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 1:1102 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-2529
Mailing Address - Country:US
Mailing Address - Phone:703-963-8860
Mailing Address - Fax:
Practice Address - Street 1:1102 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-2529
Practice Address - Country:US
Practice Address - Phone:703-963-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty