Provider Demographics
NPI:1427514611
Name:CHACKO, RESHMA S (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:RESHMA
Middle Name:S
Last Name:CHACKO
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MS
Other - First Name:RESHMA
Other - Middle Name:S
Other - Last Name:FERNANDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2121 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-4359
Mailing Address - Country:US
Mailing Address - Phone:203-909-8533
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-909-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8097363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty