Provider Demographics
NPI:1467908517
Name:CHACKO, MINI (NNP)
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 EDGEMERE RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-2807
Mailing Address - Country:US
Mailing Address - Phone:973-992-5247
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:973-322-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00655400363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care