Provider Demographics
NPI:1912451337
Name:NALLU, SIREESHA
Entity type:Individual
Prefix:
First Name:SIREESHA
Middle Name:
Last Name:NALLU
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 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:
Practice Address - Street 1:340 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4126
Practice Address - Country:US
Practice Address - Phone:928-634-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301413207Q00000X
AZ72894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine