Healthcare Provider Details

I. General information

NPI: 1003254657
Provider Name (Legal Business Name): JAISA JOSEPH PALLICKAL MSN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNAMMA ZACHARIAH RN

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BROAD ST 0815
NEW YORK NY
10004-2415
US

IV. Provider business mailing address

17 BEST ST
WESTWOOD NJ
07675-2701
US

V. Phone/Fax

Practice location:
  • Phone: 718-391-0611
  • Fax:
Mailing address:
  • Phone: 201-358-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number305563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: