Provider Demographics
NPI:1780357442
Name:BHARUCHA, NIKKI
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:BHARUCHA
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 1:28262 DIEHL RD APT 318
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3877
Mailing Address - Country:US
Mailing Address - Phone:732-781-6454
Mailing Address - Fax:
Practice Address - Street 1:1948 THREE FARMS AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-1105
Practice Address - Country:US
Practice Address - Phone:732-781-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085009407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program