Provider Demographics
NPI:1699379321
Name:CHEATHAM, MANDY LEE
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LEE
Last Name:CHEATHAM
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 1:3311 CHATEAU DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2476
Mailing Address - Country:US
Mailing Address - Phone:740-821-9543
Mailing Address - Fax:
Practice Address - Street 1:3311 CHATEAU DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2476
Practice Address - Country:US
Practice Address - Phone:740-821-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide