Healthcare Provider Details

I. General information

NPI: 1164351912
Provider Name (Legal Business Name): SRUJANA PANNEM
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 HARTFORD AVE
JOHNSTON RI
02919-3224
US

IV. Provider business mailing address

52 HILMA ST
QUINCY MA
02171-2727
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number82198
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9518113
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: