Provider Demographics
NPI:1477820090
Name:TULL, CHERRY COOPER
Entity Type:Individual
Prefix:MS
First Name:CHERRY
Middle Name:COOPER
Last Name:TULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MILLGATE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1338
Mailing Address - Country:US
Mailing Address - Phone:336-659-6062
Mailing Address - Fax:336-659-6063
Practice Address - Street 1:1400 MILLGATE DR
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1338
Practice Address - Country:US
Practice Address - Phone:336-659-6063
Practice Address - Fax:336-659-6062
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPED3362224P00000X, 224L00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter