Provider Demographics
NPI:1962787291
Name:KALLON, MBALLU P (RN)
Entity type:Individual
Prefix:
First Name:MBALLU
Middle Name:P
Last Name:KALLON
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 1:1900 GRAND CONCOURSE APT 1F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5214
Mailing Address - Country:US
Mailing Address - Phone:347-399-0742
Mailing Address - Fax:
Practice Address - Street 1:1322 CLAY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1766
Practice Address - Country:US
Practice Address - Phone:646-915-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY758198163W00000X
NY2947931164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse