Provider Demographics
NPI:1194713644
Name:ERICKSON, CHERYL LYNN (NP)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SHOREVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4813 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-3018
Practice Address - Country:US
Practice Address - Phone:260-449-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000493A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000284072OtherANTHEM
IN200209490Medicaid
IN500020243OtherRAILROAD MEDICARE
IN070830JMedicare PIN
IN000000284072OtherANTHEM
IN069860AAAAMedicare PIN