Provider Demographics
NPI:1780733154
Name:VAN ATTA, CHERI M (LMT)
Entity type:Individual
Prefix:
First Name:CHERI
Middle Name:M
Last Name:VAN ATTA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 HARBORS PORT ST
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-6312
Mailing Address - Country:US
Mailing Address - Phone:850-206-6817
Mailing Address - Fax:
Practice Address - Street 1:4140 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8313
Practice Address - Country:US
Practice Address - Phone:850-995-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2955OtherBCBS PROVIDER #