Provider Demographics
NPI:1871845693
Name:SMALL, CHERAY
Entity Type:Individual
Prefix:
First Name:CHERAY
Middle Name:
Last Name:SMALL
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 1:23528 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3257
Mailing Address - Country:US
Mailing Address - Phone:347-553-6122
Mailing Address - Fax:
Practice Address - Street 1:13 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6003
Practice Address - Country:US
Practice Address - Phone:516-823-0739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10 311713164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse