Healthcare Provider Details

I. General information

NPI: 1730783143
Provider Name (Legal Business Name): JISMI JOSHY VATHIELIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

5951 NW 80TH TER
PARKLAND FL
33067-1128
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-8333
  • Fax:
Mailing address:
  • Phone: 954-240-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11037894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: