Provider Demographics
NPI:1346380656
Name:GJERDE, CYNTHIA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:M
Last Name:GJERDE
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 1:9645 W VAN BECK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2156
Mailing Address - Country:US
Mailing Address - Phone:414-545-0631
Mailing Address - Fax:
Practice Address - Street 1:4800 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2412
Practice Address - Country:US
Practice Address - Phone:414-744-5370
Practice Address - Fax:414-744-9052
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1644163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42019900Medicaid