Healthcare Provider Details

I. General information

NPI: 1457850075
Provider Name (Legal Business Name): ANNAMMA MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

8120 255TH ST
FLORAL PARK NY
11004-1415
US

V. Phone/Fax

Practice location:
  • Phone: 718-464-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number450591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: