Healthcare Provider Details

I. General information

NPI: 1720673890
Provider Name (Legal Business Name): JOHNNIE RAE CYR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S IMPERIAL AVE STE 3
EL CENTRO CA
92243-4242
US

IV. Provider business mailing address

516 W ATEN RD STE 2
IMPERIAL CA
92251-9805
US

V. Phone/Fax

Practice location:
  • Phone: 760-339-2802
  • Fax: 760-355-9520
Mailing address:
  • Phone: 760-355-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: