Provider Demographics
NPI:1598737439
Name:POTHULA, SANDRA MERENE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MERENE
Last Name:POTHULA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 475, BOX1752
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350
Mailing Address - Country:JP
Mailing Address - Phone:0118146-896-4713
Mailing Address - Fax:
Practice Address - Street 1:PSC 475, BOX1752
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350
Practice Address - Country:JP
Practice Address - Phone:0118146-896-4713
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC169872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily