Provider Demographics
NPI:1245331859
Name:ROUSE, CYNTHIA D (CFNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:ROUSE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LINCOLN PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3262
Mailing Address - Country:US
Mailing Address - Phone:601-579-4440
Mailing Address - Fax:601-579-4460
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:STE 300
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-579-4440
Practice Address - Fax:601-579-4460
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR614505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125874Medicaid
MS00125874Medicaid