Healthcare Provider Details

I. General information

NPI: 1093668659
Provider Name (Legal Business Name): SHINY KAITHAKUZHIYIL CHACKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 IRONBOUND RD
WILLIAMSBURG VA
23188-2648
US

IV. Provider business mailing address

617 CHESDALE CT
WILLIAMSBURG VA
23188-1593
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-5161
  • Fax:
Mailing address:
  • Phone: 757-525-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001298013
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: