Provider Demographics
NPI:1679755953
Name:WALL, CHERYL ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:ELIZABETH
Last Name:WALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:CHERYL
Other - Middle Name:ELIZABETH
Other - Last Name:HANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:4211 U.S. HIGHWAY 1 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7096
Mailing Address - Country:US
Mailing Address - Phone:904-794-0854
Mailing Address - Fax:
Practice Address - Street 1:4211 U.S. HIGHWAY 1 SOUTH
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7096
Practice Address - Country:US
Practice Address - Phone:904-794-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35162225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1650OtherBLUECROSS BLUESHIELD