Provider Demographics
NPI:1225638026
Name:PINNAMARAJU, PRASANTI
Entity Type:Individual
Prefix:
First Name:PRASANTI
Middle Name:
Last Name:PINNAMARAJU
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:PO BOX 20844
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0085
Mailing Address - Country:US
Mailing Address - Phone:612-245-8710
Mailing Address - Fax:
Practice Address - Street 1:5324 FOX RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8754
Practice Address - Country:US
Practice Address - Phone:612-245-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily