Provider Demographics
NPI:1861530941
Name:JOHN, KUNJAMMA (NP)
Entity type:Individual
Prefix:
First Name:KUNJAMMA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 79TH ST
Mailing Address - Street 2:NY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-0819
Mailing Address - Country:US
Mailing Address - Phone:212-879-1600
Mailing Address - Fax:212-988-3103
Practice Address - Street 1:211 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0819
Practice Address - Country:US
Practice Address - Phone:212-879-1600
Practice Address - Fax:212-988-3103
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303081363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY95 N601Medicare ID - Type Unspecified