Basic Information
| Provider Information | |||||||||
| NPI: | 1740477025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | VONCILLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARDSON | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | VONCILLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | P O BOX 2867 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Practice Location | |||||||||
| Address1: | 4555 SAINT STEPHENS RD | ||||||||
| Address2: | |||||||||
| City: | EIGHT MILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366133563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514561399 | ||||||||
| FaxNumber: | 2514560079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-045566 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 1-045566 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0389275-22 | 01 | AL | ANCC | OTHER | 011846 | 01 | AL | MEDICARE GROUP NUMBER | OTHER | 1063439065 | 01 | AL | NPI SITE GROUP PAYEE NUMBER | OTHER | 630000013 | 05 | AL | MEDICAID |