Provider Demographics
NPI:1902360811
Name:NATHANIEL, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:NATHANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 EDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9184
Mailing Address - Country:US
Mailing Address - Phone:803-257-4811
Mailing Address - Fax:
Practice Address - Street 1:1714 EDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-9184
Practice Address - Country:US
Practice Address - Phone:803-257-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0933374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
83-1834296OtherINTERNAL REVENUE SERVICE