Basic Information
| Provider Information | |||||||||
| NPI: | 1063568558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSENZA | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D., C.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284284 | ||||||||
| FaxNumber: | 3178658355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1704 LAFAYETTE RD STE 4 | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479331071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653643120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 37001539A | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | M147140002 | 01 | IN | MEDICARE PROVIDER PTAN | OTHER |