1134149115 NPI number — MRS. CYNTHIA SUSAN SMITH CNP, ACNP

Table of content: MRS. CYNTHIA SUSAN SMITH CNP, ACNP (NPI 1134149115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134149115 NPI number — MRS. CYNTHIA SUSAN SMITH CNP, ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
CYNTHIA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP, ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAHAM
Provider Other First Name:
CYNTHIA
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ACNP-BC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1134149115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1095 PINGREE RD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-459-6655
Provider Business Mailing Address Fax Number:
847-658-9922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1095 PINGREE RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-459-6655
Provider Business Practice Location Address Fax Number:
847-658-9922
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  209-001572 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 309-001579 . This is a "IL SUBSCRIBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 041-291329 . This is a "IL REGISTERED NURSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 209-001572 . This is a "ADVANCED PRACTICE NURSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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