Basic Information
| Provider Information | |||||||||
| NPI: | 1972801629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULICKAL | ||||||||
| FirstName: | MANJJU | ||||||||
| MiddleName: | AGNES | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THADATHIL | ||||||||
| OtherFirstName: | MANJJU | ||||||||
| OtherMiddleName: | AGNES | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8558514405 | ||||||||
| Practice Location | |||||||||
| Address1: | 344 MAIN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MT. KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142423652 | ||||||||
| FaxNumber: | 9142448983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2011 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NJ00321900 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 597810 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.