1366694986 NPI number — MS. CHERYL VANESSA PURYEAR MSCP

Table of content: MS. CHERYL VANESSA PURYEAR MSCP (NPI 1366694986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366694986 NPI number — MS. CHERYL VANESSA PURYEAR MSCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURYEAR
Provider First Name:
CHERYL
Provider Middle Name:
VANESSA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSCP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366694986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
561 W NELSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-6814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-357-4108
Provider Business Mailing Address Fax Number:
907-357-4178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5851 E MAYFLOWER CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-357-6808
Provider Business Practice Location Address Fax Number:
907-373-1135
Provider Enumeration Date:
10/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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