Basic Information
| Provider Information | |||||||||
| NPI: | 1841569142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | KORDEK | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KORDEK | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | DIANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1609 PASADENA AVE S | ||||||||
| Address2: | SUITE 3M | ||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337074565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273842016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1609 PASADENA AVE S | ||||||||
| Address2: | SUITE 3M | ||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337074565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273842016 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2011 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9235090 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | GY799Z | 01 | FL | PTAN | OTHER |