Provider Demographics
NPI:1750974663
Name:CHERY, KETTY (APRN)
Entity type:Individual
Prefix:
First Name:KETTY
Middle Name:
Last Name:CHERY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1200
Mailing Address - Country:US
Mailing Address - Phone:800-640-3451
Mailing Address - Fax:
Practice Address - Street 1:8320 W SUNRISE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-5432
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF11200594363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily