Provider Demographics
NPI:1972062594
Name:JO, ANU KORULLA
Entity Type:Individual
Prefix:
First Name:ANU
Middle Name:KORULLA
Last Name:JO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-3238
Mailing Address - Country:US
Mailing Address - Phone:469-964-3508
Mailing Address - Fax:
Practice Address - Street 1:307 HIGHPOINT DR
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-3238
Practice Address - Country:US
Practice Address - Phone:469-964-3518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138151363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health