Healthcare Provider Details

I. General information

NPI: 1912524687
Provider Name (Legal Business Name): JUDI SUNDARAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 04/16/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 MARTIN LUTHER KING JR WAY FL 1
BERKELEY CA
94704-1108
US

IV. Provider business mailing address

3069 E KYNE ST APT 107
SAN MATEO CA
94403-3676
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax: 518-756-0812
Mailing address:
  • Phone: 617-930-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95017148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2302318
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: