Healthcare Provider Details

I. General information

NPI: 1598737439
Provider Name (Legal Business Name): SANDRA MERENE POTHULA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475, BOX1752
FPO AP
96350
JP

IV. Provider business mailing address

PSC 475, BOX1752
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 01181468964713
  • Fax:
Mailing address:
  • Phone: 01181468964713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number169872
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: