Provider Demographics
NPI:1356497119
Name:BALLENTINE, CYNTHIA RENEE (OTR)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:RENEE
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NYKIEL CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4244
Mailing Address - Country:US
Mailing Address - Phone:636-527-5336
Mailing Address - Fax:636-527-5337
Practice Address - Street 1:811 NYKIEL CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4244
Practice Address - Country:US
Practice Address - Phone:636-527-5336
Practice Address - Fax:636-527-5337
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist