Provider Demographics
NPI:1093183006
Name:VANDEWEGE, CHERYL L
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:L
Last Name:VANDEWEGE
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 1:1915 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2300
Mailing Address - Country:US
Mailing Address - Phone:865-331-1720
Mailing Address - Fax:865-331-2823
Practice Address - Street 1:1915 WHITE AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2300
Practice Address - Country:US
Practice Address - Phone:865-331-1720
Practice Address - Fax:865-331-2823
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704159114363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ071411Medicaid