Provider Demographics
NPI:1134488844
Name:NULLA, SONITA
Entity Type:Individual
Prefix:MRS
First Name:SONITA
Middle Name:
Last Name:NULLA
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 1:1107 KINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6917
Mailing Address - Country:US
Mailing Address - Phone:240-705-3324
Mailing Address - Fax:202-503-2363
Practice Address - Street 1:1518 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-3216
Practice Address - Country:US
Practice Address - Phone:240-705-3324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR217800363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1134488844Medicaid