Healthcare Provider Details

I. General information

NPI: 1215922745
Provider Name (Legal Business Name): CYNTHIA A GARDINER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2745
US

IV. Provider business mailing address

1218 N MAIN ST
PUEBLO CO
81003-2828
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-7877
  • Fax: 719-543-7882
Mailing address:
  • Phone: 719-543-7877
  • Fax: 719-543-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number169561
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: