Provider Demographics
NPI:1386226793
Name:KOOLIPURACKAL, SUJARANI ANTOCHEN (AGPCNP)
Entity Type:Individual
Prefix:
First Name:SUJARANI
Middle Name:ANTOCHEN
Last Name:KOOLIPURACKAL
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SAM PERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4456
Mailing Address - Country:US
Mailing Address - Phone:540-741-3900
Mailing Address - Fax:
Practice Address - Street 1:1200 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4456
Practice Address - Country:US
Practice Address - Phone:540-741-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181137363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care