Provider Demographics
NPI:1245761915
Name:CHEADLE, MANDI
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:CHEADLE
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 1:5290 WHITE LN NW
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9510
Mailing Address - Country:US
Mailing Address - Phone:740-962-2357
Mailing Address - Fax:
Practice Address - Street 1:5290 WHITE LANE
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758
Practice Address - Country:US
Practice Address - Phone:740-962-2357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN119183164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse