Provider Demographics
NPI:1164727301
Name:CHERRY, CHANTALL MARIE
Entity Type:Individual
Prefix:MS
First Name:CHANTALL
Middle Name:MARIE
Last Name:CHERRY
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:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-1642
Mailing Address - Country:US
Mailing Address - Phone:307-789-0664
Mailing Address - Fax:307-222-0614
Practice Address - Street 1:400 S KENDRICK AVE
Practice Address - Street 2:SUITE 104C
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3848
Practice Address - Country:US
Practice Address - Phone:307-685-7105
Practice Address - Fax:307-222-0614
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management