Healthcare Provider Details

I. General information

NPI: 1083053102
Provider Name (Legal Business Name): PRAJAKTA SULE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 SONORA AVE
SOUTH SAN FRANCISCO CA
94080-5940
US

IV. Provider business mailing address

29 SONORA AVE
SOUTH SAN FRANCISCO CA
94080-5940
US

V. Phone/Fax

Practice location:
  • Phone: 678-429-4855
  • Fax:
Mailing address:
  • Phone: 678-429-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number24248
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: