Provider Demographics
NPI:1063552495
Name:UTLEY-BRENEMAN, CYNTHIA LYNN (DPM)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYNN
Last Name:UTLEY-BRENEMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:MISS
Other - First Name:CYNTHIA
Other - Middle Name:LYNN
Other - Last Name:UTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 5134
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5134
Mailing Address - Country:US
Mailing Address - Phone:765-426-1766
Mailing Address - Fax:765-296-9842
Practice Address - Street 1:720 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-8182
Practice Address - Country:US
Practice Address - Phone:765-296-9842
Practice Address - Fax:765-296-9842
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000682A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100129410AMedicaid
IN407560AOtherMEDICARE PTAN
IN407560AOtherMEDICARE PTAN