Healthcare Provider Details

I. General information

NPI: 1356002604
Provider Name (Legal Business Name): SUMY THAKOLKARAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6335 HOSPITAL PKWY STE 208
JOHNS CREEK GA
30097-1551
US

IV. Provider business mailing address

595 HURRICANE SHOALS RD NW STE 100
LAWRENCEVILLE GA
30046-8762
US

V. Phone/Fax

Practice location:
  • Phone: 404-645-7150
  • Fax:
Mailing address:
  • Phone: 404-645-7150
  • Fax: 678-433-9152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN199752
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: