Provider Demographics
NPI:1710961016
Name:ROSENBERRY, CYNTHIA (CRNA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:ROSENBERRY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:SECOND FLOOR MAIN TOWER
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:228-865-3281
Mailing Address - Fax:228-867-5117
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:SECOND FLOOR MAIN TOWER
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-865-3281
Practice Address - Fax:228-867-5117
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP01399367500000X
MS901632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1393967Medicaid
LA1393967Medicaid