Provider Demographics
NPI:1306694617
Name:NAKKALA, SUPRAJA (MD)
Entity type:Individual
Prefix:MS
First Name:SUPRAJA
Middle Name:
Last Name:NAKKALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 OWEN DRIVE
Mailing Address - Street 2:BOX 138
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-4000
Mailing Address - Fax:
Practice Address - Street 1:1638 OWEN DRIVE
Practice Address - Street 2:BOX 138
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-615-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2025-01-27
Deactivation Date:2025-01-10
Deactivation Code:
Reactivation Date:2025-01-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program