Provider Demographics
NPI:1275169187
Name:KUMAR, SUDHA RAJ (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:RAJ
Last Name:KUMAR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2654
Mailing Address - Country:US
Mailing Address - Phone:423-543-2584
Mailing Address - Fax:423-722-2060
Practice Address - Street 1:1500 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2654
Practice Address - Country:US
Practice Address - Phone:423-543-2584
Practice Address - Fax:423-722-2060
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27158363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ059853Medicaid