Provider Demographics
NPI:1255772562
Name:MATHEW, LEELAMMA J (APN)
Entity type:Individual
Prefix:
First Name:LEELAMMA
Middle Name:J
Last Name:MATHEW
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 COLONIAL ARMS RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7608
Mailing Address - Country:US
Mailing Address - Phone:908-688-4827
Mailing Address - Fax:
Practice Address - Street 1:310 CENTRAL AVE
Practice Address - Street 2:102
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2835
Practice Address - Country:US
Practice Address - Phone:973-395-1550
Practice Address - Fax:973-395-3711
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00448400363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health