Provider Demographics
NPI:1760482327
Name:BURLEY, CHERYL LEE (CNP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LEE
Last Name:BURLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0178
Mailing Address - Country:US
Mailing Address - Phone:269-657-2550
Mailing Address - Fax:269-657-2285
Practice Address - Street 1:1743 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0927
Practice Address - Country:US
Practice Address - Phone:269-423-7028
Practice Address - Fax:269-423-8282
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704126846363L00000X, 363LP0808X
AZAP8175363LP0808X
AZAP8176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114987663Medicaid
MI0H06012031Medicare PIN
MI114987663Medicaid