Provider Demographics
NPI:1184690786
Name:FODNESS, CYNTHIA SUSAN (CNS)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:SUSAN
Last Name:FODNESS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26164 TWIN LAKES TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9537
Mailing Address - Country:US
Mailing Address - Phone:574-273-8543
Mailing Address - Fax:574-283-1208
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-234-0061
Practice Address - Fax:574-283-1209
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28123166A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN955190UUMedicare ID - Type Unspecified
Q27998Medicare UPIN