Basic Information
| Provider Information | |||||||||
| NPI: | 1568071132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 DEER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GOREVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629392417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187130818 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2020 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209021488 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209021488 | 01 | IL | APN LICENSE | OTHER |