Provider Demographics
NPI:1831287226
Name:SOOKNANAN, POONAM M (DPT)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:M
Last Name:SOOKNANAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1350
Mailing Address - Country:US
Mailing Address - Phone:201-978-7224
Mailing Address - Fax:
Practice Address - Street 1:23 GODFREY AVE
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:NJ
Practice Address - Zip Code:07068-1350
Practice Address - Country:US
Practice Address - Phone:201-978-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00929300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ093753UFBMedicaid
NJ093753UFBMedicare ID - Type Unspecified