Provider Demographics
NPI:1134637804
Name:MAMAT, CHERYL
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:MAMAT
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 1:5764 LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5764 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-8734
Practice Address - Country:US
Practice Address - Phone:623-826-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI219844163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty