Provider Demographics
NPI:1831276625
Name:UTIC, CYNTHIA ANN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:UTIC
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 CARRIER CREEK BLVD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1215
Mailing Address - Country:US
Mailing Address - Phone:616-458-6901
Mailing Address - Fax:616-351-2685
Practice Address - Street 1:3641 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-3665
Practice Address - Country:US
Practice Address - Phone:616-531-3070
Practice Address - Fax:616-351-2685
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704114498363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4839885Medicaid