Provider Demographics
NPI:1861963159
Name:JOSE, AJOMOL KURISUNKAL
Entity type:Individual
Prefix:
First Name:AJOMOL
Middle Name:KURISUNKAL
Last Name:JOSE
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 1:16194 NW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1220
Mailing Address - Country:US
Mailing Address - Phone:954-559-2601
Mailing Address - Fax:
Practice Address - Street 1:16194 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1220
Practice Address - Country:US
Practice Address - Phone:954-559-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9225913363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily