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General NPI Number Information
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NPI Number | 1063422319
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Entity Type | Individual
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Provider Name | THRESIAMMA IDICHANDY NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 08/09/2006
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 234 W CAMPBELL RD
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City | RICHARDSON
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State | TX
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Zip | 75080-3512
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Country | US
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Telephone | 972-474-3221
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Fax | 512-782-9316
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Provider Business Mailing Address
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Address Line | 9618 PEACH TREE LN
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City | ROWLETT
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State | TX
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Zip | 75089-8508
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Country | US
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Telephone | 248-408-8116
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Fax | 248-408-8116
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1207120
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704171067
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License Number State | MI
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