Provider Demographics
NPI:1386015451
Name:SURESH, SANJULA (NP)
Entity Type:Individual
Prefix:
First Name:SANJULA
Middle Name:
Last Name:SURESH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SANJULA
Other - Middle Name:
Other - Last Name:DAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4133 SEYMOUR DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-4395
Mailing Address - Country:US
Mailing Address - Phone:248-376-9271
Mailing Address - Fax:
Practice Address - Street 1:4133 SEYMOUR DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-4395
Practice Address - Country:US
Practice Address - Phone:248-376-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291952163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse