Provider Demographics
NPI:1861997868
Name:KOOTTIYANIYIL, NIKITA
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:KOOTTIYANIYIL
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 1:5023 LOCKRIDGE SKY LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-6805
Mailing Address - Country:US
Mailing Address - Phone:973-518-3184
Mailing Address - Fax:
Practice Address - Street 1:2409 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1112
Practice Address - Country:US
Practice Address - Phone:973-518-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program