Healthcare Provider Details

I. General information

NPI: 1053401893
Provider Name (Legal Business Name): CHERYL LYNNE DEETS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 RIBAUT RD
PORT ROYAL SC
29935-1403
US

IV. Provider business mailing address

423 MEDICAL PARK DR SUITE 100
LENOIR CITY TN
37772-5640
US

V. Phone/Fax

Practice location:
  • Phone: 843-770-0676
  • Fax:
Mailing address:
  • Phone: 865-271-6600
  • Fax: 865-271-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1826
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51246
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: