Provider Demographics
NPI:1710222641
Name:JOHN, SUJA MARY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUJA
Middle Name:MARY
Last Name:JOHN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 NW 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-2350
Mailing Address - Country:US
Mailing Address - Phone:954-435-1506
Mailing Address - Fax:
Practice Address - Street 1:700 N HIATUS RD STE 213
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5206
Practice Address - Country:US
Practice Address - Phone:954-392-9026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9267880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily