Basic Information
| Provider Information | |||||||||
| NPI: | 1720189368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLIN | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 6905A | WY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 118441500 | 05 | WY | MEDICAID | 504824210005 | 05 | UT | MEDICAID |