Provider Demographics
NPI:1396362646
Name:PRINCE-MATTATHIL, NISHA SUSAN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:SUSAN
Last Name:PRINCE-MATTATHIL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3912
Mailing Address - Country:US
Mailing Address - Phone:631-386-3402
Mailing Address - Fax:
Practice Address - Street 1:789 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3912
Practice Address - Country:US
Practice Address - Phone:631-386-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1792786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily