Provider Demographics
NPI:1720057565
Name:DOTSON, CYNTHIA C (NP)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:C
Last Name:DOTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 AVENT DR STE 105
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-7575
Mailing Address - Fax:662-227-6575
Practice Address - Street 1:965 AVENT DR STE 105
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7575
Practice Address - Fax:662-227-6575
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR561126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02775800Medicaid
MS02775800Medicaid
P76469Medicare UPIN
MS500001673Medicare ID - Type Unspecified