Provider Demographics
NPI:1104421585
Name:SURUNNA, SUCHADA RACHAPAT
Entity type:Individual
Prefix:
First Name:SUCHADA
Middle Name:RACHAPAT
Last Name:SURUNNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BURNHAM PL
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2956
Mailing Address - Country:US
Mailing Address - Phone:818-929-6236
Mailing Address - Fax:
Practice Address - Street 1:24 BURNHAM PL
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2956
Practice Address - Country:US
Practice Address - Phone:818-929-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329305-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse