Healthcare Provider Details

I. General information

NPI: 1639452261
Provider Name (Legal Business Name): CYNTHIA CHISM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W. HOSPITAL WAY
WHITERIVER AZ
85941
US

IV. Provider business mailing address

PO BOX 80039 CIBECUE HEALTH CENTER
CIBECUE AZ
85911
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-3684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR20022
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: