Provider Demographics
NPI:1386209229
Name:VARGHESE, BENITA SHAJI
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:SHAJI
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GARRETT CT
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6739
Mailing Address - Country:US
Mailing Address - Phone:845-352-8548
Mailing Address - Fax:
Practice Address - Street 1:223 N VAN DIEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2726
Practice Address - Country:US
Practice Address - Phone:201-447-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00897300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily