Healthcare Provider Details

I. General information

NPI: 1891350005
Provider Name (Legal Business Name): CYNTHIA GORDON NICKERSON RN CDE CMC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARTLETT REGIONAL HOSPITAL 3260 HOSPITAL DRIVE
DOUGLAS AK
99801
US

IV. Provider business mailing address

2126 2ND ST
DOUGLAS AK
99824-5115
US

V. Phone/Fax

Practice location:
  • Phone: 907-796-8649
  • Fax: 907-796-8574
Mailing address:
  • Phone: 907-957-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberNURR19700
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: