Provider Demographics
NPI:1235268269
Name:FAIRMAN, CYNTHIA L (RD CDE)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:FAIRMAN
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 MORAGA WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5763
Mailing Address - Country:US
Mailing Address - Phone:916-786-2235
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-536-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508221133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist