Provider Demographics
NPI:1164113841
Name:CHACKO, NIYA KARUKAMATTOM
Entity Type:Individual
Prefix:
First Name:NIYA
Middle Name:KARUKAMATTOM
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 1:14510 38TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-5390
Mailing Address - Country:US
Mailing Address - Phone:425-305-9007
Mailing Address - Fax:
Practice Address - Street 1:1550 N 115TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8401
Practice Address - Country:US
Practice Address - Phone:877-694-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60948690163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical