Provider Demographics
NPI:1790944684
Name:PANICKER, NISANTH (MS,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:NISANTH
Middle Name:
Last Name:PANICKER
Suffix:
Gender:M
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 12TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4920
Mailing Address - Country:US
Mailing Address - Phone:253-841-3422
Mailing Address - Fax:206-445-4043
Practice Address - Street 1:920 12TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4920
Practice Address - Country:US
Practice Address - Phone:253-841-3422
Practice Address - Fax:206-445-4043
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist