Provider Demographics
NPI:1053568832
Name:PROVOST, CHERYL DIANE (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:DIANE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MRS
Other - First Name:CHERYL
Other - Middle Name:DIANE
Other - Last Name:PROVOST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:28 STRATFORD TER
Mailing Address - Street 2:28 STRATFORD TERRACE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2213
Mailing Address - Country:US
Mailing Address - Phone:413-747-1748
Mailing Address - Fax:
Practice Address - Street 1:235 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1100
Practice Address - Country:US
Practice Address - Phone:413-726-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA270377163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics