Provider Demographics
NPI:1578986584
Name:KLAISLE, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:KLAISLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:GARBUTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 SUNSET BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3791
Mailing Address - Country:US
Mailing Address - Phone:530-886-3679
Mailing Address - Fax:530-886-3670
Practice Address - Street 1:1000 SUNSET BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3791
Practice Address - Country:US
Practice Address - Phone:530-886-3679
Practice Address - Fax:530-886-3670
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN296004363LW0102X
CANPF1317363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health