Provider Demographics
NPI:1356463756
Name:RICHARDSON, CYNTHIA JENE (HOME CARE PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JENE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:HOME CARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WAMPLER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-5122
Mailing Address - Country:US
Mailing Address - Phone:937-278-3473
Mailing Address - Fax:
Practice Address - Street 1:36 WAMPLER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-5122
Practice Address - Country:US
Practice Address - Phone:937-278-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2402251171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2402251Medicaid