Provider Demographics
NPI:1356066815
Name:JOHNY, ANANNYA SHAJI
Entity type:Individual
Prefix:
First Name:ANANNYA
Middle Name:SHAJI
Last Name:JOHNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-2536
Mailing Address - Country:US
Mailing Address - Phone:201-474-5189
Mailing Address - Fax:
Practice Address - Street 1:8 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2536
Practice Address - Country:US
Practice Address - Phone:201-474-5189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350053363LF0000X
NJ26NJ15087300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily