Provider Demographics
NPI:1417224999
Name:DOUGLAS, CHERYL JEAN (CHP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:JEAN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:AK
Mailing Address - Zip Code:99786-0110
Mailing Address - Country:US
Mailing Address - Phone:907-445-2129
Mailing Address - Fax:907-445-2179
Practice Address - Street 1:110 MAIN STREET
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:AK
Practice Address - Zip Code:99786-0110
Practice Address - Country:US
Practice Address - Phone:907-445-2129
Practice Address - Fax:907-445-2179
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10-1057-II171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor