Healthcare Provider Details

I. General information

NPI: 1235221581
Provider Name (Legal Business Name): LEELAMMA V KOIKKAL R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 FOREST AVE
STATEN ISLAND NY
10303-1506
US

IV. Provider business mailing address

175 WESTWOOD AVE
STATEN ISLAND NY
10314-5414
US

V. Phone/Fax

Practice location:
  • Phone: 718-447-0200
  • Fax: 718-981-1431
Mailing address:
  • Phone: 718-494-6258
  • Fax: 718-981-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number304062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: