Provider Demographics
NPI:1659093698
Name:IDICHANDY, MARIAMMA MATHEW
Entity Type:Individual
Prefix:
First Name:MARIAMMA
Middle Name:MATHEW
Last Name:IDICHANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3809
Mailing Address - Country:US
Mailing Address - Phone:215-983-4486
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3098
Practice Address - Country:US
Practice Address - Phone:215-456-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA210460994163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical