Healthcare Provider Details

I. General information

NPI: 1235266149
Provider Name (Legal Business Name): CYNTHIA DIANE SHIELDS RN,BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W ROSE ST
WALLA WALLA WA
99362-1662
US

IV. Provider business mailing address

1120 W ROSE ST
WALLA WALLA WA
99362-1662
US

V. Phone/Fax

Practice location:
  • Phone: 509-524-5333
  • Fax:
Mailing address:
  • Phone: 509-524-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberRN00134310
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: