Provider Demographics
NPI:1295412146
Name:MATHEW, KALA JESSY (AGACNP-BC)
Entity type:Individual
Prefix:MS
First Name:KALA
Middle Name:JESSY
Last Name:MATHEW
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 LAKEVILLE ROAD, ENTRANCE B
Mailing Address - Street 2:
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-734-8900
Mailing Address - Fax:
Practice Address - Street 1:1406 CECILY DR
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566
Practice Address - Country:US
Practice Address - Phone:516-205-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF432665-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care