Provider Demographics
NPI:1407935901
Name:PALLESEN, CYNTHIA JANE (CNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JANE
Last Name:PALLESEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:CINDY
Other - Middle Name:JANE
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 S STATE ST
Practice Address - Street 2:STE 113
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4501
Practice Address - Country:US
Practice Address - Phone:605-622-4000
Practice Address - Fax:605-626-3399
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR141881-1363L00000X
SDR017439363LF0000X
NDR36847363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19855Medicaid
TX8Y4021OtherBCBS PVN
SDR017439OtherSD RN LICENSE NUMBER
SDMP0470550OtherCONTROLLED SUBSTANCE CERT
MNR141881-1OtherMN RN LICENSURE
MNR141881-1OtherMN RN LICENSURE
MNS-93647Medicare UPIN
SDR017439OtherSD RN LICENSE NUMBER