Provider Demographics
NPI:1790158186
Name:PANICHIKUDIYIL, SUBY ABY (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUBY
Middle Name:ABY
Last Name:PANICHIKUDIYIL
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:4131 W LOOMIS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2057
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:414-325-3770
Practice Address - Street 1:4131 W LOOMIS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2057
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:414-325-3770
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2018-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI6643-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner