Provider Demographics
NPI:1295051167
Name:SPEAKE, CHERYL PREMILA (DO)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:PREMILA
Last Name:SPEAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5156
Mailing Address - Country:US
Mailing Address - Phone:479-314-1101
Mailing Address - Fax:479-314-4704
Practice Address - Street 1:3224 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5050
Practice Address - Country:US
Practice Address - Phone:479-314-4810
Practice Address - Fax:479-314-4829
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10037147208000000X
ARE-9186208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2487OtherTN MEDICAL LIC
TNQ001054Medicaid
200601840AOtherMEDICAID SOONERCARE
OK200601840AMedicaid
AR209981003Medicaid
TNQ001054Medicaid