1891350005 NPI number — MS. CYNTHIA GORDON NICKERSON RN CDE CMC

Table of content: MS. CYNTHIA GORDON NICKERSON RN CDE CMC (NPI 1891350005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891350005 NPI number — MS. CYNTHIA GORDON NICKERSON RN CDE CMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICKERSON
Provider First Name:
CYNTHIA
Provider Middle Name:
GORDON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN CDE CMC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891350005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2126 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99824-5115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-957-2999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BARTLETT REGIONAL HOSPITAL
Provider Second Line Business Practice Location Address:
3260 HOSPITAL DRIVE
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-796-8649
Provider Business Practice Location Address Fax Number:
907-796-8574
Provider Enumeration Date:
05/02/2019

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: 163WD0400X , with the licence number:  NURR19700 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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