Healthcare Provider Details

I. General information

NPI: 1598093775
Provider Name (Legal Business Name): VIRGINIA CHEATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

400 N PEPPER AVE
COLTON CA
92324-1801
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-3144
  • Fax: 909-580-2165
Mailing address:
  • Phone: 909-580-3144
  • Fax: 909-580-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number301241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: