Provider Demographics
NPI:1215221577
Name:STORY, CYNTHIA LOUISE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LOUISE
Last Name:STORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1648
Mailing Address - Country:US
Mailing Address - Phone:218-834-8018
Mailing Address - Fax:218-834-8019
Practice Address - Street 1:401 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1648
Practice Address - Country:US
Practice Address - Phone:218-834-8018
Practice Address - Fax:218-834-8019
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2011-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN353080310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility