Provider Demographics
NPI:1356634596
Name:CHERY-QUILES, MILDRED MAURISSA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:MAURISSA
Last Name:CHERY-QUILES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:MILDRED
Other - Middle Name:MAURISSA
Other - Last Name:CHERY-QUILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:13518 123RD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3725
Mailing Address - Country:US
Mailing Address - Phone:516-236-5213
Mailing Address - Fax:
Practice Address - Street 1:13518 123RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3725
Practice Address - Country:US
Practice Address - Phone:516-236-5213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305625-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY305625-1Medicaid