Provider Demographics
NPI:1972768646
Name:SUNEETHA, MARY PRIMROSE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PRIMROSE
Last Name:SUNEETHA
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 1:902 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3427
Mailing Address - Country:US
Mailing Address - Phone:626-358-8964
Mailing Address - Fax:
Practice Address - Street 1:902 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3427
Practice Address - Country:US
Practice Address - Phone:626-358-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No374700000XNursing Service Related ProvidersTechnician