Healthcare Provider Details

I. General information

NPI: 1417837436
Provider Name (Legal Business Name): RENU CHACKO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

IV. Provider business mailing address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-7009
  • Fax:
Mailing address:
  • Phone: 405-341-7009
  • Fax: 405-330-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number225259
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: