Healthcare Provider Details

I. General information

NPI: 1053568832
Provider Name (Legal Business Name): CHERYL DIANE PROVOST REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHERYL DIANE PROVOST REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 CHESTNUT ST
SPRINGFIELD MA
01103-1100
US

IV. Provider business mailing address

28 STRATFORD TER 28 STRATFORD TERRACE
SPRINGFIELD MA
01108-2213
US

V. Phone/Fax

Practice location:
  • Phone: 413-726-0503
  • Fax:
Mailing address:
  • Phone: 413-747-1748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number270377
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: