=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487956140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUJITHA NICHOLAS THOTTAM ANP/GNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2010
-----------------------------------------------------
Last Update Date | 04/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8268 164TH ST N BUILDING-733
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-883-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82-68 164TH STREET, QUEENS HOSPITAL CENTER N BUILDING-733
-----------------------------------------------------
City | QUEENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-358-4001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F305475-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | F340781-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------