Provider Demographics
NPI:1437527413
Name:CHACKO, LENY V
Entity Type:Individual
Prefix:MRS
First Name:LENY
Middle Name:V
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 1:16953 W SERRANDA DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-9465
Mailing Address - Country:US
Mailing Address - Phone:847-918-7663
Mailing Address - Fax:
Practice Address - Street 1:16953 W SERRANDA DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9465
Practice Address - Country:US
Practice Address - Phone:847-918-7663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041346167163W00000X
IL209013196363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherSOCIAL SECURITY NUMBER