Healthcare Provider Details

I. General information

NPI: 1326696121
Provider Name (Legal Business Name): BEENA MANCHERIL FNP - BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BEENA MATHACHAN NP

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E SHORE RD
GREAT NECK NY
11023-2410
US

IV. Provider business mailing address

310 E SHORE RD
GREAT NECK NY
11023-2410
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-8657
  • Fax:
Mailing address:
  • Phone: 516-482-8657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF344363-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: