Provider Demographics
NPI:1780176461
Name:ANDERSON, CHERELLE L (ST)
Entity type:Individual
Prefix:
First Name:CHERELLE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 BROOKWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-3463
Mailing Address - Country:US
Mailing Address - Phone:229-672-9212
Mailing Address - Fax:
Practice Address - Street 1:1368 BROOKWOOD DR SE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-3463
Practice Address - Country:US
Practice Address - Phone:229-672-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor