Provider Demographics
NPI:1417313180
Name:MOONNUMACKAL, BESSY M (NP-C)
Entity Type:Individual
Prefix:
First Name:BESSY
Middle Name:M
Last Name:MOONNUMACKAL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8527 VILLAGE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5507
Mailing Address - Country:US
Mailing Address - Phone:210-946-5633
Mailing Address - Fax:210-946-5632
Practice Address - Street 1:2515 CASTROVILLE RD STE 1
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3361
Practice Address - Country:US
Practice Address - Phone:210-946-5633
Practice Address - Fax:210-946-5632
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129068363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner