Healthcare Provider Details

I. General information

NPI: 1215707567
Provider Name (Legal Business Name): RONY THANNIMOOTTILCHIRAYIL CHACKO AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 RAINTREE CIR
ALLEN TX
75013-4912
US

IV. Provider business mailing address

4025 BASHFUL DR
PLANO TX
75093-6977
US

V. Phone/Fax

Practice location:
  • Phone: 972-908-2000
  • Fax:
Mailing address:
  • Phone: 469-866-2643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1141167
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1141167
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1141167
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: