Provider Demographics
NPI:1407286479
Name:BLANK, CHERYL (NP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6615
Mailing Address - Country:US
Mailing Address - Phone:727-734-4000
Mailing Address - Fax:727-724-4110
Practice Address - Street 1:703 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6615
Practice Address - Country:US
Practice Address - Phone:727-734-4000
Practice Address - Fax:727-724-4110
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO9370324363LF0000X
FL9370324363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily