Healthcare Provider Details

I. General information

NPI: 1508193574
Provider Name (Legal Business Name): CYNDIA MARIE MOCK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 SAN PEDRO DR NE STE 220
ALBUQUERQUE NM
87113-2480
US

IV. Provider business mailing address

PO BOX 1506
CHEHALIS WA
98532-0409
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-4466
  • Fax: 505-797-2275
Mailing address:
  • Phone: 360-242-3008
  • Fax: 360-807-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number01220
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704251927
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: