MEDICARE: JEEVANTHA NANAYAKKARA FNP -BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	1026821	TX

General Provider Information

NPI Number	:	1366129934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEEVANTHA NANAYAKKARA FNP -BC

Provider Business Mailing Address
First Line	:	3201 S AUSTIN AVE STE 325
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-7642
Country	:	US
Telephone Number	:	512-717-5077
Fax Number	:	512-713-0844

Provider Business Practice Location Address
First Line	:	3201 S AUSTIN AVE STE 325
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-7642
Country	:	US
Telephone Number	:	512-717-5077
Fax Number	:	512-713-0844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	11/04/2025

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