Provider Demographics
NPI:1528253564
Name:JOHN, MARIAMMA PUNNOOSE (RN)
Entity type:Individual
Prefix:MS
First Name:MARIAMMA
Middle Name:PUNNOOSE
Last Name:JOHN
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 1:16 SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1424
Mailing Address - Country:US
Mailing Address - Phone:516-297-1129
Mailing Address - Fax:
Practice Address - Street 1:16 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:ROSLYN HTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1402
Practice Address - Country:US
Practice Address - Phone:516-297-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4793401163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01803516Medicaid