Provider Demographics
NPI:1932228939
Name:POULOSE, MOLY (NP)
Entity Type:Individual
Prefix:
First Name:MOLY
Middle Name:
Last Name:POULOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-3097
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:201-225-2106
Practice Address - Street 1:880 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:07646-3097
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:201-225-2106
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY488126163W00000X
NYF333216363L00000X
NJ26NN10644300363LF0000X
NJ26NO10644300163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner