Provider Demographics
NPI:1447854351
Name:VARGHESE, ANNIE SHINY
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:SHINY
Last Name:VARGHESE
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 1:1706 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3241
Mailing Address - Country:US
Mailing Address - Phone:516-785-3123
Mailing Address - Fax:
Practice Address - Street 1:1706 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3241
Practice Address - Country:US
Practice Address - Phone:516-785-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045672390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program