Provider Demographics
NPI:1982686838
Name:SANNE, PREMA V (MD)
Entity Type:Individual
Prefix:MRS
First Name:PREMA
Middle Name:V
Last Name:SANNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 RIVER POINTE DR
Mailing Address - Street 2:1009
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-4763
Mailing Address - Country:US
Mailing Address - Phone:229-869-0683
Mailing Address - Fax:229-889-7393
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-253-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0479412084P0800X
CAC1614492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000973343BMedicaid
GA26BDJMFMedicare ID - Type Unspecified
GA000973343BMedicaid