Provider Demographics
NPI:1114674652
Name:STAVISH, CYNTHIA ANN (MSN, AHCNS, APRN)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:ANN
Last Name:STAVISH
Suffix:
Gender:F
Credentials:MSN, AHCNS, APRN
Other - Prefix:MRS
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:LYCZKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN
Mailing Address - Street 1:5673 JENNI LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5721
Mailing Address - Country:US
Mailing Address - Phone:651-208-9291
Mailing Address - Fax:651-340-5143
Practice Address - Street 1:5673 JENNI LN
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55110-5721
Practice Address - Country:US
Practice Address - Phone:651-208-9291
Practice Address - Fax:651-340-5143
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN522364SA2100X, 364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care MedicineGroup - Multi-Specialty
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care