Healthcare Provider Details

I. General information

NPI: 1831938521
Provider Name (Legal Business Name): ROSAMMA CHACKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 OLD ORANGEBURG RD
ORANGEBURG NY
10962-1157
US

IV. Provider business mailing address

104 LAWRENCE ST
TAPPAN NY
10983-2625
US

V. Phone/Fax

Practice location:
  • Phone: 845-680-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number682440
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: