Provider Demographics
NPI:1063422319
Name:IDICHANDY, THRESIAMMA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:THRESIAMMA
Middle Name:
Last Name:IDICHANDY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9618 PEACH TREE LN
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-8508
Mailing Address - Country:US
Mailing Address - Phone:248-408-8116
Mailing Address - Fax:248-408-8116
Practice Address - Street 1:234 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3512
Practice Address - Country:US
Practice Address - Phone:972-474-3221
Practice Address - Fax:512-782-9316
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1207120363LF0000X
MI4704171067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704171067OtherREGISTERED NNURSE
TX1207120OtherTEXAS