Provider Demographics
NPI:1104010412
Name:DUPUIS, CHERYL (NP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:DUPUIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001162363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00635927OtherMEDICARE RAIROAD
MO000010688OtherMEDICARE GROUP PTAN
MO1104010412Medicaid
MOCP9089OtherRAILROAD GROUP
MO000010688OtherMEDICARE GROUP PTAN