Healthcare Provider Details

I. General information

NPI: 1568005171
Provider Name (Legal Business Name): ANCHALA THYKKOOTTATHIL JOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2019
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7403 COMMONWEALTH BLVD
BELLEROSE NY
11426-1839
US

IV. Provider business mailing address

1821 NEW HYDE PARK RD
NEW HYDE PARK NY
11040-2027
US

V. Phone/Fax

Practice location:
  • Phone: 516-305-0710
  • Fax:
Mailing address:
  • Phone: 516-305-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number665017
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: