Provider Demographics
NPI:1841886116
Name:ISHAM, CINDY MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:MARIE
Last Name:ISHAM
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-3537
Mailing Address - Country:US
Mailing Address - Phone:970-278-7385
Mailing Address - Fax:
Practice Address - Street 1:501 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-3537
Practice Address - Country:US
Practice Address - Phone:970-278-7385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0108867163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty