Healthcare Provider Details

I. General information

NPI: 1336631886
Provider Name (Legal Business Name): ANISHA CHAKKACHERIL NINAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANISHA CHAKKACHERIL CRNP

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7350 VAN DUSEN RD STE 210
LAUREL MD
20707-5268
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 301-395-5500
  • Fax: 301-498-7346
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number862730
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR235759
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: