Provider Demographics
NPI:1679820799
Name:SMITH, CYNTHIA RUTH (ACNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:RUTH
Last Name:SMITH
Suffix:
Gender:
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:589 GARFIELD ST STE 201
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6301
Practice Address - Country:US
Practice Address - Phone:662-680-5565
Practice Address - Fax:662-680-5654
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872258363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04938577Medicaid
AL157854Medicaid
MS04938577Medicaid