Provider Demographics
NPI:1154173466
Name:SUMMERVILLE, CHEYENNE (CERTIFIED COMMUNITY)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:CERTIFIED COMMUNITY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W PRATT ST STE 880
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-6829
Mailing Address - Country:US
Mailing Address - Phone:667-214-1301
Mailing Address - Fax:
Practice Address - Street 1:120 PENN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1082
Practice Address - Country:US
Practice Address - Phone:410-706-2501
Practice Address - Fax:410-328-3379
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01115-22-A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker