Provider Demographics
NPI:1265473649
Name:KICKLIGHTER-HALL, CHERYL L (CNP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:KICKLIGHTER-HALL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4255
Mailing Address - Country:US
Mailing Address - Phone:229-227-5500
Mailing Address - Fax:229-227-5505
Practice Address - Street 1:3053 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:MEIGS
Practice Address - State:GA
Practice Address - Zip Code:31765-4308
Practice Address - Country:US
Practice Address - Phone:229-683-3406
Practice Address - Fax:229-683-3407
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN032598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P62864Medicare UPIN
GA50BBBBSMedicare ID - Type Unspecified