Provider Demographics
NPI:1003399809
Name:BOMMAKANTI, RAJITHA (RN)
Entity type:Individual
Prefix:
First Name:RAJITHA
Middle Name:
Last Name:BOMMAKANTI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13225 CARIS CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3249
Mailing Address - Country:US
Mailing Address - Phone:919-656-1029
Mailing Address - Fax:
Practice Address - Street 1:13225 CARIS CT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-3249
Practice Address - Country:US
Practice Address - Phone:919-656-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-08
Last Update Date:2018-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208614163WC0400X, 163WC1500X, 163WD0400X, 163WD1100X, 163WH0200X, 163WH0500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN208614OtherRN