Provider Demographics
NPI:1467708404
Name:MIKELSON, CYNTHIA REDFERN (LAC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:REDFERN
Last Name:MIKELSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:CHENEY
Other - Last Name:MIKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:195 W HIGHWAY 246
Mailing Address - Street 2:
Mailing Address - City:BUELLTON
Mailing Address - State:CA
Mailing Address - Zip Code:93427-9459
Mailing Address - Country:US
Mailing Address - Phone:805-686-8555
Mailing Address - Fax:805-686-8556
Practice Address - Street 1:195 W HIGHWAY 246
Practice Address - Street 2:
Practice Address - City:BUELLTON
Practice Address - State:CA
Practice Address - Zip Code:93427-9459
Practice Address - Country:US
Practice Address - Phone:805-686-8555
Practice Address - Fax:805-686-8556
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9535171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC9535OtherSTATE MEDICAL LICENSE