Healthcare Provider Details

I. General information

NPI: 1205399474
Provider Name (Legal Business Name): CYNTHIA LOUISE LANDERS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TURNER MCCALL BLVD SW
ROME GA
30165-5621
US

IV. Provider business mailing address

55 SURREY TRL SE
ROME GA
30161-5946
US

V. Phone/Fax

Practice location:
  • Phone: 706-509-6110
  • Fax:
Mailing address:
  • Phone: 706-936-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN142457
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberRN142457
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: