Provider Demographics
NPI:1992989966
Name:KAVULLA, SANDRA ANITA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANITA
Last Name:KAVULLA
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 1:760 HOSPITAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417-0760
Mailing Address - Country:US
Mailing Address - Phone:406-338-6369
Mailing Address - Fax:
Practice Address - Street 1:4936 DEERWOOD AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32466-2028
Practice Address - Country:US
Practice Address - Phone:406-338-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9164999163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse