Provider Demographics
NPI:1134149115
Name:SMITH, CYNTHIA SUSAN (CNP, ACNP)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:SUSAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP, ACNP
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:SUSAN
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:1095 PINGREE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1726
Mailing Address - Country:US
Mailing Address - Phone:815-459-6655
Mailing Address - Fax:847-658-9922
Practice Address - Street 1:1095 PINGREE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1726
Practice Address - Country:US
Practice Address - Phone:815-459-6655
Practice Address - Fax:847-658-9922
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001572363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL309-001579OtherIL SUBSCRIBER
IL041-291329OtherIL REGISTERED NURSE
IL209-001572OtherADVANCED PRACTICE NURSE
ILQ00097Medicare UPIN
IL209-001572OtherADVANCED PRACTICE NURSE