Healthcare Provider Details

I. General information

NPI: 1386209229
Provider Name (Legal Business Name): BENITA SHAJI VARGHESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

IV. Provider business mailing address

1 GARRETT CT
CHESTNUT RIDGE NY
10977-6739
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-8000
  • Fax:
Mailing address:
  • Phone: 845-352-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00897300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: