Provider Demographics
NPI:1033671748
Name:DOMALAPALLY, SRUTHI
Entity Type:Individual
Prefix:
First Name:SRUTHI
Middle Name:
Last Name:DOMALAPALLY
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 1:99 VISTA MONTANA APT 3215
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2377
Mailing Address - Country:US
Mailing Address - Phone:240-812-2002
Mailing Address - Fax:
Practice Address - Street 1:65 N 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6207
Practice Address - Country:US
Practice Address - Phone:408-279-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011027363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner