Provider Demographics
NPI:1063287894
Name:KALLAH, JOSEPHINE (MSPA-C)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:KALLAH
Suffix:
Gender:F
Credentials:MSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PROSPECT AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1974
Mailing Address - Country:US
Mailing Address - Phone:908-359-8980
Mailing Address - Fax:
Practice Address - Street 1:20 PROSPECT AVE STE 702
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1974
Practice Address - Country:US
Practice Address - Phone:908-359-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031010363A00000X
NJ25MP00817100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant