Provider Demographics
NPI:1710026497
Name:WEATHERFORD, SHERRY LYNNE (LMT)
Entity Type:Individual
Prefix:MR
First Name:SHERRY
Middle Name:LYNNE
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 W AVOCADO ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-5680
Mailing Address - Country:US
Mailing Address - Phone:352-220-0167
Mailing Address - Fax:352-795-4732
Practice Address - Street 1:9030 W FORT ISLAND TRL BLDG 10
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-2412
Practice Address - Country:US
Practice Address - Phone:352-220-0167
Practice Address - Fax:352-795-4732
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA16326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7345OtherPIN BLUECROSS BLUE SHILED