Provider Demographics
NPI:1972083707
Name:SUDANAGUNTA, SWARNA LATHA
Entity Type:Individual
Prefix:
First Name:SWARNA
Middle Name:LATHA
Last Name:SUDANAGUNTA
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 1:111 S AUSTIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-3261
Mailing Address - Country:US
Mailing Address - Phone:302-747-6780
Mailing Address - Fax:
Practice Address - Street 1:809 E NAVARRO AVE
Practice Address - Street 2:
Practice Address - City:DE LEON
Practice Address - State:TX
Practice Address - Zip Code:76444-1275
Practice Address - Country:US
Practice Address - Phone:254-893-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2125970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant