Provider Demographics
NPI:1710573159
Name:CHACKO, SUSAN (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8311
Mailing Address - Country:US
Mailing Address - Phone:516-941-7930
Mailing Address - Fax:
Practice Address - Street 1:5200 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7709
Practice Address - Country:US
Practice Address - Phone:516-941-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140734363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care