Provider Demographics
NPI:1043418775
Name:ICKE, CINDY FAE (LAC, OMD)
Entity Type:Individual
Prefix:DR
First Name:CINDY
Middle Name:FAE
Last Name:ICKE
Suffix:
Gender:F
Credentials:LAC, OMD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:FAE
Other - Last Name:ICKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC, OMD
Mailing Address - Street 1:3532 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-1612
Mailing Address - Country:US
Mailing Address - Phone:415-565-0658
Mailing Address - Fax:
Practice Address - Street 1:760 MARKET ST
Practice Address - Street 2:SUITE 759
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2401
Practice Address - Country:US
Practice Address - Phone:415-262-0083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 1508171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist