Provider Demographics
NPI:1760187140
Name:NANDALA, DAVID NICHOLAS (BA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NICHOLAS
Last Name:NANDALA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 N ITHICA ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-4002
Mailing Address - Country:US
Mailing Address - Phone:313-979-8612
Mailing Address - Fax:
Practice Address - Street 1:740 N ITHICA ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-4002
Practice Address - Country:US
Practice Address - Phone:313-979-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered