Provider Demographics
NPI:1588181614
Name:FEDELE, CHERYL ANN
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:FEDELE
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 1:8800 CIDER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2565
Mailing Address - Country:US
Mailing Address - Phone:978-835-7684
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD UNIT B
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-473-6666
Practice Address - Fax:415-473-4113
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95112363163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY4569552OtherDRIVERS LICENSE