Provider Demographics
NPI:1912612912
Name:CHEATHAM, ANGELA NOEL (LPN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NOEL
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LIFETIME WAY
Mailing Address - Street 2:APT 705
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2372
Mailing Address - Country:US
Mailing Address - Phone:585-745-0571
Mailing Address - Fax:
Practice Address - Street 1:87 N CLINTON AVE
Practice Address - Street 2:SUITE 429
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1455
Practice Address - Country:US
Practice Address - Phone:585-745-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2025-01-13
Deactivation Date:2024-10-18
Deactivation Code:
Reactivation Date:2025-01-13
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
NY351127164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant