| Doctor Name: | MR. JERRY IDICULLA CHANDY |
| NPI Number: | 1023447695 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | N.P. |
| License Number: | 4704276954 |
| Business Practice Address: | 1675 Kingsway Ct Ste 1 Trenton, MI - 481831958 |
| Business Phone Number: | 7346768530 |
| Business Fax Number: | |
| Mailing Address: | 1675 Kingsway Ct Ste 1, TRENTON |
| State: | MI |
| Postal Code: | 481831958 |
| Phone Number: | 7346768530 |
| Fax Number: | |
| NPI Enumeration Date: | 11/05/2013 |
| NPI Last Update Date: | 11/05/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | 4704276954 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |