Provider Demographics
NPI:1154923928
Name:GAMMON, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GAMMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12091 BYERS AVE NE
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-9724
Mailing Address - Country:US
Mailing Address - Phone:133-093-3888
Mailing Address - Fax:
Practice Address - Street 1:12091 BYERS AVE NE
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9724
Practice Address - Country:US
Practice Address - Phone:133-093-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01420563747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0142056Medicaid