Provider Demographics
NPI:1619511276
Name:KALLICKAL, JAMES MATHEW (ACAGNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MATHEW
Last Name:KALLICKAL
Suffix:
Gender:M
Credentials:ACAGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-6770
Mailing Address - Country:US
Mailing Address - Phone:832-263-0962
Mailing Address - Fax:
Practice Address - Street 1:3406 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-4148
Practice Address - Country:US
Practice Address - Phone:346-570-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142979363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care