MEDICARE: ANITA CHACKO RNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	699985	TX

General Provider Information

NPI Number	:	1346449535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA CHACKO RNP-C

Provider Business Mailing Address
First Line	:	9696 SKILLMAN ST
Second Line	:	SUITE 285 LB 42
City	:	DALLAS
State	:	TX
Zip	:	75243-8264
Country	:	US
Telephone Number	:	214-348-7611
Fax Number	:	214-348-0129

Provider Business Practice Location Address
First Line	:	7441 MARVIN D LOVE FWY
Second Line	:	SUITE 300
City	:	DALLAS
State	:	TX
Zip	:	75237-3490
Country	:	US
Telephone Number	:	972-572-1998
Fax Number	:	972-572-4842

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	07/17/2007

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