Provider Demographics
NPI:1629523881
Name:SULUSI, ANDREA (MA 60663287)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SULUSI
Suffix:
Gender:F
Credentials:MA 60663287
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7829
Mailing Address - Country:US
Mailing Address - Phone:253-576-3303
Mailing Address - Fax:
Practice Address - Street 1:3837 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7829
Practice Address - Country:US
Practice Address - Phone:253-576-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60663287172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker