Provider Demographics
NPI:1083108807
Name:BROGDON, SHERRY R
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:R
Last Name:BROGDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 HERITAGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650-5830
Mailing Address - Country:US
Mailing Address - Phone:912-850-1265
Mailing Address - Fax:
Practice Address - Street 1:176 HERITAGE HILL ROAD
Practice Address - Street 2:
Practice Address - City:WILLACOOCHEE
Practice Address - State:GA
Practice Address - Zip Code:31650
Practice Address - Country:US
Practice Address - Phone:912-850-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor