Healthcare Provider Details

I. General information

NPI: 1770474710
Provider Name (Legal Business Name): CYNTHIA PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 LOVECHIO DR
MISHAWAKA IN
46544-5639
US

IV. Provider business mailing address

831 LOVECHIO DR
MISHAWAKA IN
46544-5639
US

V. Phone/Fax

Practice location:
  • Phone: 360-628-1131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28283909A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: