Healthcare Provider Details

I. General information

NPI: 1588181614
Provider Name (Legal Business Name): CHERYL ANN FEDELE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD UNIT B
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

8800 CIDER SPRINGS RD
SEBASTOPOL CA
95472-2565
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6666
  • Fax: 415-473-4113
Mailing address:
  • Phone: 978-835-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95112363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: