MEDICARE: MRS. SANDRA MERENE POTHULA FNP

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	363LF0000X	Family Nurse Practitioner	169872	NC

General Provider Information

NPI Number	:	1598737439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA MERENE POTHULA FNP

Provider Business Mailing Address
First Line	:	PSC 475, BOX1752
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96350
Country	:	JP
Telephone Number	:	01181468964713
Fax Number	:

Provider Business Practice Location Address
First Line	:	PSC 475, BOX1752
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96350
Country	:	JP
Telephone Number	:	01181468964713
Fax Number	:

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

Provider Enumeration Date	:	02/05/2006
Last Update Date	:	07/08/2007

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