Provider Demographics
NPI:1902140072
Name:KOLENCHERY, MERCY J (APN)
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:J
Last Name:KOLENCHERY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3767
Mailing Address - Country:US
Mailing Address - Phone:773-772-8876
Mailing Address - Fax:773-252-3091
Practice Address - Street 1:2004 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3767
Practice Address - Country:US
Practice Address - Phone:773-772-8876
Practice Address - Fax:773-252-3091
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009890363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily