Provider Demographics
NPI:1902138217
Name:NIDADAVOLU, REKHA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:REKHA
Middle Name:
Last Name:NIDADAVOLU
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:DR
Other - First Name:REKHA
Other - Middle Name:
Other - Last Name:PINJALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM-D
Mailing Address - Street 1:4745 OLD CANOE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1400
Mailing Address - Country:US
Mailing Address - Phone:305-905-9316
Mailing Address - Fax:
Practice Address - Street 1:4745 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1400
Practice Address - Country:US
Practice Address - Phone:305-905-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44664183500000X
MA24667183500000X
FLPA9111839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA24667OtherPHARMACIST LICENSE
FLPS44664OtherFLORIDA BOARD OF PHARMACY
FLPA9111839OtherFLORIDA PHYSICIAN ASSISTANT BOARD