Provider Demographics
NPI:1629354485
Name:ELY, CYNTHIA ANN
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANN
Last Name:ELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4529 BLUEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3328
Mailing Address - Country:US
Mailing Address - Phone:937-276-4412
Mailing Address - Fax:
Practice Address - Street 1:4529 BLUEBERRY AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3328
Practice Address - Country:US
Practice Address - Phone:937-276-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH143507164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse