Provider Demographics
NPI:1841039575
Name:JOSE, AMALA VALLOMPURAYIDATHIL
Entity type:Individual
Prefix:
First Name:AMALA
Middle Name:VALLOMPURAYIDATHIL
Last Name:JOSE
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 1:44 VALLEY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1027
Mailing Address - Country:US
Mailing Address - Phone:201-289-2092
Mailing Address - Fax:
Practice Address - Street 1:140 OLD ORANGEBURG RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1157
Practice Address - Country:US
Practice Address - Phone:845-680-8546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566597163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult