Healthcare Provider Details

I. General information

NPI: 1194639815
Provider Name (Legal Business Name): CHERYL A CORLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 BENNINGTON AVE
YOUNGSTOWN OH
44505-3508
US

IV. Provider business mailing address

1666 LANCASTER DR
YOUNGSTOWN OH
44511-1037
US

V. Phone/Fax

Practice location:
  • Phone: 330-740-4005
  • Fax:
Mailing address:
  • Phone: 330-740-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.159313.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: