Provider Demographics
NPI:1639457724
Name:RADER, CHERYL LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:RADER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7366
Mailing Address - Fax:502-568-7114
Practice Address - Street 1:3500 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1732
Practice Address - Country:US
Practice Address - Phone:812-238-1555
Practice Address - Fax:812-238-1557
Is Sole Proprietor?:No
Enumeration Date:2011-07-24
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28121420A363LF0000X
IN71003648A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2048003Medicare PIN