Provider Demographics
NPI:1619381381
Name:NICHOLSON, CYNTHIA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LYNN
Other - Last Name:KOSLOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301510051207NP0225X
MN66969207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology