Provider Demographics
NPI:1245651744
Name:PRAKASAM, SAMMANASU (RN)
Entity type:Individual
Prefix:
First Name:SAMMANASU
Middle Name:
Last Name:PRAKASAM
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 1:419 LISK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1779
Mailing Address - Country:US
Mailing Address - Phone:718-494-1067
Mailing Address - Fax:
Practice Address - Street 1:275 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2709
Practice Address - Country:US
Practice Address - Phone:718-447-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY680504163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse