Healthcare Provider Details

I. General information

NPI: 1033100110
Provider Name (Legal Business Name): CINDY JANE SALMON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 CROSSMAN RD
FAIRBANKS AK
99712-1413
US

IV. Provider business mailing address

828 CROSSMAN RD
FAIRBANKS AK
99712-1413
US

V. Phone/Fax

Practice location:
  • Phone: 907-457-6688
  • Fax: 907-782-4232
Mailing address:
  • Phone: 907-457-6688
  • Fax: 907-782-4232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0030
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: