Healthcare Provider Details

I. General information

NPI: 1407241763
Provider Name (Legal Business Name): SOFIYA NUKALO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5506 TANG PL
COLUMBIA MD
21045-2629
US

IV. Provider business mailing address

5506 TANG PL
COLUMBIA MD
21045-2629
US

V. Phone/Fax

Practice location:
  • Phone: 215-806-8374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR262910
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: