Provider Demographics
NPI:1720673890
Name:CYR, JOHNNIE RAE (FNP)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:RAE
Last Name:CYR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W ATEN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:
Practice Address - Street 1:1600 S IMPERIAL AVE STE 3
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4242
Practice Address - Country:US
Practice Address - Phone:760-339-2802
Practice Address - Fax:760-355-9520
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016559363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily