Provider Demographics
NPI:1871035030
Name:THELIKADA PALLIYA GURUGE, CHANIKA MADHUSHANI ALWIS (RN)
Entity Type:Individual
Prefix:MISS
First Name:CHANIKA
Middle Name:MADHUSHANI ALWIS
Last Name:THELIKADA PALLIYA GURUGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Mailing Address - Street 1:9219 SIBLEY HOLE RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-8874
Mailing Address - Country:US
Mailing Address - Phone:501-455-6166
Mailing Address - Fax:
Practice Address - Street 1:9219 SIBLEY HOLE RD
Practice Address - Street 2:BUILDING B
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-8874
Practice Address - Country:US
Practice Address - Phone:501-455-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR102438163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse