Healthcare Provider Details

I. General information

NPI: 1336655976
Provider Name (Legal Business Name): CHERYL LYNN CONNELL RN, CCRN, LMT, MMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERYL LYNN GRAHAM RN, CCRN, LMT, MMT

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 PROFESSIONAL CIR STE A
MARTINEZ GA
30907-8234
US

IV. Provider business mailing address

155 MOREHEAD DR
MARTINEZ GA
30907-1396
US

V. Phone/Fax

Practice location:
  • Phone: 762-302-8007
  • Fax:
Mailing address:
  • Phone: 706-284-9481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN173280
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License NumberMT010651
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number173280
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: