Provider Demographics
NPI:1689733156
Name:MATHEW, SOSAMMA K (ARNP)
Entity Type:Individual
Prefix:
First Name:SOSAMMA
Middle Name:K
Last Name:MATHEW
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3262 VINELAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4839
Mailing Address - Country:US
Mailing Address - Phone:866-422-7367
Mailing Address - Fax:407-809-5243
Practice Address - Street 1:3262 VINELAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-4839
Practice Address - Country:US
Practice Address - Phone:866-422-7367
Practice Address - Fax:407-809-5243
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA1106083164W00000X
FLARNP1809802363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308052800Medicaid