Provider Demographics
NPI:1821778929
Name:VEJJADHAM, NATRADA
Entity Type:Individual
Prefix:MISS
First Name:NATRADA
Middle Name:
Last Name:VEJJADHAM
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 1:40 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1052
Mailing Address - Country:US
Mailing Address - Phone:206-965-5594
Mailing Address - Fax:
Practice Address - Street 1:40 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1052
Practice Address - Country:US
Practice Address - Phone:206-965-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92043225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist