Healthcare Provider Details

I. General information

NPI: 1679887954
Provider Name (Legal Business Name): SANGHAMITRA KODUKULA RN, BSN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1275 YORK AVE
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-6840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number551691
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number551691
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: