Provider Demographics
NPI:1720607260
Name:VASUDEVAN, MAYILATHAL (NP)
Entity Type:Individual
Prefix:
First Name:MAYILATHAL
Middle Name:
Last Name:VASUDEVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VACCARO RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-1324
Mailing Address - Country:US
Mailing Address - Phone:609-213-8902
Mailing Address - Fax:
Practice Address - Street 1:3140 PRINCETON PIKE FL 2
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2330
Practice Address - Country:US
Practice Address - Phone:609-895-1919
Practice Address - Fax:609-895-2900
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NRI4696700163WN0800X
NJ26NJ01240200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience