Provider Demographics
NPI:1497350920
Name:CHEMMALAKUZHY, JENSINE TOMI (NP)
Entity Type:Individual
Prefix:
First Name:JENSINE
Middle Name:TOMI
Last Name:CHEMMALAKUZHY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENSINE
Other - Middle Name:ILLIKATTIL
Other - Last Name:TOMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 116116
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 PARK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3466
Practice Address - Country:US
Practice Address - Phone:706-227-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN252456363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse