Provider Demographics
NPI:1720387343
Name:IDICULA, SUSAMMA THOMAS (ANP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAMMA
Middle Name:THOMAS
Last Name:IDICULA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 106TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3923
Mailing Address - Country:US
Mailing Address - Phone:212-870-5000
Mailing Address - Fax:212-870-4905
Practice Address - Street 1:120 WEST 106 STREET
Practice Address - Street 2:THE JEWISH HOME & HOSPITAL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-0000
Practice Address - Country:US
Practice Address - Phone:212-870-5000
Practice Address - Fax:212-870-4905
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305565-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health