Provider Demographics
NPI:1366448193
Name:VANDEURSEN, CHERYL (CNM)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:VANDEURSEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 N COURT ST PMB355
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307
Mailing Address - Country:US
Mailing Address - Phone:219-681-6995
Mailing Address - Fax:219-757-6481
Practice Address - Street 1:417 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9419
Practice Address - Country:US
Practice Address - Phone:219-987-2641
Practice Address - Fax:219-987-5586
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000112A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ18765Medicare UPIN
IN202790IIMedicare ID - Type Unspecified