Provider Demographics
NPI:1023447695
Name:CHANDY, JERRY IDICULLA (NP)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:IDICULLA
Last Name:CHANDY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 KINGSWAY CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1958
Mailing Address - Country:US
Mailing Address - Phone:734-676-8530
Mailing Address - Fax:
Practice Address - Street 1:1675 KINGSWAY CT STE 1
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1958
Practice Address - Country:US
Practice Address - Phone:734-676-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276954363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health