Provider Demographics
NPI:1972801629
Name:PULICKAL, MANJJU AGNES (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MANJJU
Middle Name:AGNES
Last Name:PULICKAL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MANJJU
Other - Middle Name:AGNES
Other - Last Name:THADATHIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:344 MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MT. KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549
Practice Address - Country:US
Practice Address - Phone:914-242-3652
Practice Address - Fax:914-244-8983
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00321900367500000X
NY597810367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered