Healthcare Provider Details

I. General information

NPI: 1194298406
Provider Name (Legal Business Name): JYOTHI MAMMEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 RICHMOND AVE STE 1
STATEN ISLAND NY
10312-5637
US

IV. Provider business mailing address

682 FOREST AVE
STATEN ISLAND NY
10310-2507
US

V. Phone/Fax

Practice location:
  • Phone: 718-966-5556
  • Fax:
Mailing address:
  • Phone: 718-370-3730
  • Fax: 718-698-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: