Provider Demographics
NPI:1831336171
Name:JEGANNATHAN, SUMATHI (ANP)
Entity type:Individual
Prefix:
First Name:SUMATHI
Middle Name:
Last Name:JEGANNATHAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7903 ORION CIR
Mailing Address - Street 2:APT B 101
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-3101
Mailing Address - Country:US
Mailing Address - Phone:314-719-6119
Mailing Address - Fax:410-788-4545
Practice Address - Street 1:405 FREDERICK RD
Practice Address - Street 2:STE 11
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4645
Practice Address - Country:US
Practice Address - Phone:410-788-4411
Practice Address - Fax:410-788-4545
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168437363L00000X
MDAC001027363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health