Provider Demographics
NPI:1629768197
Name:KNOWLTON, CYNTHIA MARIE (MSN, RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:MSN, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:602-409-0499
Practice Address - Street 1:20440 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3240
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-910-2949
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN291425363LP0808X
AZ291425363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ142694Medicaid