Healthcare Provider Details

I. General information

NPI: 1295051167
Provider Name (Legal Business Name): CHERYL PREMILA SPEAKE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 S 70TH ST
FORT SMITH AR
72903-5050
US

IV. Provider business mailing address

2901 S 74TH ST
FORT SMITH AR
72903-5156
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-4810
  • Fax: 479-314-4829
Mailing address:
  • Phone: 479-314-1101
  • Fax: 479-314-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10037147
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-9186
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: