=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972016384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNNYSSIX, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2017
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2410 LUNA RD # 204
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75006-6538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-469-7072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2410 LUNA RD # 204
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75006-6538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-844-7072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NIDISH JOSE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 817-823-5464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | AP134568
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------