Provider Demographics
NPI:1942897665
Name:KILLIP, CYNTHIA MARIE (PR)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:KILLIP
Suffix:
Gender:F
Credentials:PR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8404 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4339
Mailing Address - Country:US
Mailing Address - Phone:501-663-0708
Mailing Address - Fax:501-313-4062
Practice Address - Street 1:8404 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4339
Practice Address - Country:US
Practice Address - Phone:501-663-0708
Practice Address - Fax:501-313-4062
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR120175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120Medicaid