Basic Information
| Provider Information | |||||||||
| NPI: | 1093183006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDEWEGE | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653311720 | ||||||||
| FaxNumber: | 8653312823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653311720 | ||||||||
| FaxNumber: | 8653312823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704159114 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | Q071411 | 05 | TN | MEDICAID |