Provider Demographics
NPI:1649216078
Name:RALYEA, CHERYL (CRN)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:RALYEA
Suffix:
Gender:F
Credentials:CRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NOBLE ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:14813-1122
Mailing Address - Country:US
Mailing Address - Phone:585-596-9156
Mailing Address - Fax:
Practice Address - Street 1:4884 ROUTE 19 S
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NY
Practice Address - Zip Code:14813-9506
Practice Address - Country:US
Practice Address - Phone:585-268-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006959B363LA2100X
NYF333369-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA077560D68Medicare ID - Type Unspecified