Provider Demographics
NPI:1790734531
Name:LAEDER, CYNTHIA LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:LAEDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LEE
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-987-5000
Mailing Address - Fax:810-985-2633
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-987-5000
Practice Address - Fax:810-985-2633
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704121920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704121920OtherLICENSE NUMBER