Provider Demographics
NPI:1134703754
Name:CHACKO, SIBI
Entity Type:Individual
Prefix:
First Name:SIBI
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 SUNSET CT # 18
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-1003
Mailing Address - Country:US
Mailing Address - Phone:214-418-9216
Mailing Address - Fax:
Practice Address - Street 1:10325 LAKE JUNE RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-5312
Practice Address - Country:US
Practice Address - Phone:214-928-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAG03190020363LG0600X
TXAP141408363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology