Healthcare Provider Details

I. General information

NPI: 1013480102
Provider Name (Legal Business Name): CYNTHIA WINSOR-MERCURIO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N ADAIR ST
CORNELIUS OR
97113-8900
US

IV. Provider business mailing address

PO BOX 6149
ALOHA OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-359-5564
  • Fax: 503-434-8597
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-434-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10194358
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: