Provider Demographics
NPI:1033202163
Name:SMALL, CYNTHIA CAROL (CNP)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:CAROL
Last Name:SMALL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:CAROL
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1891 PAW PAW AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2647
Mailing Address - Country:US
Mailing Address - Phone:269-861-0768
Mailing Address - Fax:269-926-8528
Practice Address - Street 1:190 W EMPIRE AVE # 1
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-7422
Practice Address - Country:US
Practice Address - Phone:269-926-8535
Practice Address - Fax:269-926-8528
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704095150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner