Provider Demographics
NPI:1831777267
Name:HORNBACK, CHEYENNE JARAE
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:JARAE
Last Name:HORNBACK
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 1:2805 FAWN LILY RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-1048
Mailing Address - Country:US
Mailing Address - Phone:580-465-7030
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program