Provider Demographics
NPI:1164029252
Name:MARTIN, CYNTHIA (CINDY) M (RN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA (CINDY)
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EXCEPTIONAL PROGRAM OFFICE, 1118 W. AZTEC BLVD.
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410
Mailing Address - Country:US
Mailing Address - Phone:505-334-3695
Mailing Address - Fax:505-599-4388
Practice Address - Street 1:401 RIO PECOS RD
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1646
Practice Address - Country:US
Practice Address - Phone:505-334-2621
Practice Address - Fax:505-599-4391
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR34985163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1919Medicaid