Healthcare Provider Details

I. General information

NPI: 1518115724
Provider Name (Legal Business Name): CYNTHIA STOUDMIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 23RD ST
WHEATLEY HEIGHTS NY
11798-2105
US

IV. Provider business mailing address

PO BOX 6030
FREEPORT NY
11520-0698
US

V. Phone/Fax

Practice location:
  • Phone: 631-643-3012
  • Fax:
Mailing address:
  • Phone: 631-643-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number474349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: