Basic Information
| Provider Information | |||||||||
| NPI: | 1215674759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUNNUMMEL | ||||||||
| FirstName: | THRESIAMMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| OtherLastName: | KUNNUMMEL | ||||||||
| OtherFirstName: | THRESIAMMA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1124 85TH TER N APT D | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337023315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275994512 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 7TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278251100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2022 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9340350 | FL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.