Provider Demographics
NPI:1053910570
Name:CUNNINGHAM, COURTNEY
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 E REGENT DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-7530
Mailing Address - Country:US
Mailing Address - Phone:701-333-8844
Mailing Address - Fax:
Practice Address - Street 1:3712 E REGENT DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-7530
Practice Address - Country:US
Practice Address - Phone:701-333-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1465324385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1465324Medicaid