Healthcare Provider Details

I. General information

NPI: 1861170631
Provider Name (Legal Business Name): KRISHNA SANJEEV KAKKERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14016 34TH AVE APT 1005
FLUSHING NY
11354-3061
US

IV. Provider business mailing address

14016 34TH AVE APT 1005
FLUSHING NY
11354-3061
US

V. Phone/Fax

Practice location:
  • Phone: 972-951-0520
  • Fax:
Mailing address:
  • Phone: 972-951-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number358500
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number856353
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: