Provider Demographics
NPI:1689029480
Name:CHERRY, EQUILLA V (APRN)
Entity Type:Individual
Prefix:
First Name:EQUILLA
Middle Name:V
Last Name:CHERRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:EQUILLA
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:
Practice Address - Street 1:1835 GILMORE AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3017
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9293530363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020480700Medicaid