Provider Demographics
NPI:1063903201
Name:ROY, NISHA ANN
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:ANN
Last Name:ROY
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 1:1923 COFFEE RD STE 12
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2708
Mailing Address - Country:US
Mailing Address - Phone:209-409-8454
Mailing Address - Fax:
Practice Address - Street 1:1923 COFFEE RD STE 12
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2708
Practice Address - Country:US
Practice Address - Phone:209-409-8454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95008421207KA0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy