Provider Demographics
NPI:1295704666
Name:FISH, CYNTHIA B (APN)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:B
Last Name:FISH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10266
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0104
Mailing Address - Country:US
Mailing Address - Phone:731-664-7949
Mailing Address - Fax:731-664-6141
Practice Address - Street 1:29 N STAR DR
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6656
Practice Address - Country:US
Practice Address - Phone:731-664-7949
Practice Address - Fax:731-664-6141
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010795Medicaid
TN36405511Medicare PIN
TNP00310271Medicare PIN
Q45779Medicare UPIN