Provider Demographics
NPI:1528131349
Name:VANDEMARK, CHERYL B (PT)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:B
Last Name:VANDEMARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W ROAD 1 N
Mailing Address - Street 2:STE A
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5943
Mailing Address - Country:US
Mailing Address - Phone:928-442-0005
Mailing Address - Fax:928-442-0660
Practice Address - Street 1:3117 STILLWATER DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-442-0005
Practice Address - Fax:928-442-0660
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ72712Medicare ID - Type Unspecified