Provider Demographics
NPI:1215301981
Name:WIDEMAN, CHERYL HALL (NP)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:HALL
Last Name:WIDEMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:YVONNE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3065 MOUNT MORIAH DR
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38075-7231
Mailing Address - Country:US
Mailing Address - Phone:901-734-4278
Mailing Address - Fax:
Practice Address - Street 1:77 ANTOSKI RD.
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:AK
Practice Address - Zip Code:99741
Practice Address - Country:US
Practice Address - Phone:907-656-1366
Practice Address - Fax:907-459-3845
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
AK174519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No282N00000XHospitalsGeneral Acute Care Hospital