Provider Demographics
NPI:1962020875
Name:LIST, SHERYL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 MADISON DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:KY
Mailing Address - Zip Code:41048-7399
Mailing Address - Country:US
Mailing Address - Phone:859-444-2286
Mailing Address - Fax:
Practice Address - Street 1:4015 EXECUTIVE PARK DR STE 320
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-4015
Practice Address - Country:US
Practice Address - Phone:513-563-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018525363LP0808X
OHAPRN.CNP.0026892363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0415158Medicaid