=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649897547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL VETTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2020
-----------------------------------------------------
Last Update Date | 07/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1034 S BRENTWOOD BLVD STE 1540
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-295-7521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 816 E 47TH PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-295-7521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043.107111
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------