Provider Demographics
NPI:1508136797
Name:ROBERTSON, CHERISE LEANN
Entity Type:Individual
Prefix:MS
First Name:CHERISE
Middle Name:LEANN
Last Name:ROBERTSON
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 1:774 LAVETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-5115
Mailing Address - Country:US
Mailing Address - Phone:317-523-0002
Mailing Address - Fax:
Practice Address - Street 1:774 LAVETTE AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5115
Practice Address - Country:US
Practice Address - Phone:317-523-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INHHA1102201251E00000X
INCNA0029645251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health