Provider Demographics
NPI:1750770145
Name:BANTLE, CHERIE
Entity type:Individual
Prefix:
First Name:CHERIE
Middle Name:
Last Name:BANTLE
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 1:2324 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6541
Mailing Address - Country:US
Mailing Address - Phone:810-858-3647
Mailing Address - Fax:
Practice Address - Street 1:2324 10TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6541
Practice Address - Country:US
Practice Address - Phone:810-858-3647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703097732164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse