Provider Demographics
NPI:1881886653
Name:BOYNTON, CYNTHIA G (LICENSED DIETICIAN N)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:G
Last Name:BOYNTON
Suffix:
Gender:F
Credentials:LICENSED DIETICIAN N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LINCOLN WAY EAST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544
Mailing Address - Country:US
Mailing Address - Phone:574-259-5653
Mailing Address - Fax:574-259-5654
Practice Address - Street 1:410 LINCOLN WAY EAST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544
Practice Address - Country:US
Practice Address - Phone:574-259-5653
Practice Address - Fax:574-259-5654
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635133OtherBLUE CROSS BLUE SHIELD