Healthcare Provider Details

I. General information

NPI: 1063191450
Provider Name (Legal Business Name): CHERYL LAVERTUE MCDANIEL PMHNP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W BROAD AVE STE B
ALBANY GA
31707-4397
US

IV. Provider business mailing address

100 S MADISON ST
THOMASVILLE GA
31792-5473
US

V. Phone/Fax

Practice location:
  • Phone: 229-430-4140
  • Fax:
Mailing address:
  • Phone: 229-236-0831
  • Fax: 229-236-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN146978
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN146978
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: