Provider Demographics
NPI:1396235420
Name:MATHEW, SISY JOSE (RN)
Entity type:Individual
Prefix:MRS
First Name:SISY
Middle Name:JOSE
Last Name:MATHEW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PADDOCK ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2900
Mailing Address - Country:US
Mailing Address - Phone:631-793-8682
Mailing Address - Fax:
Practice Address - Street 1:11 PADDOCK ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2900
Practice Address - Country:US
Practice Address - Phone:631-793-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY422425163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse