Provider Demographics
NPI:1063612661
Name:FIACCO, CYNTHIA MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:FIACCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 VERDUGO WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012
Mailing Address - Country:US
Mailing Address - Phone:805-384-8071
Mailing Address - Fax:805-987-1927
Practice Address - Street 1:5051 VERDUGO WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012
Practice Address - Country:US
Practice Address - Phone:805-384-8071
Practice Address - Fax:805-987-1927
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033399415Medicaid
CANP17104OtherCA NP LICENSE
CA1063612661Medicaid
CAZZZ50355YOtherBS/TRIWEST
CA1063612661Medicaid
CAW21724Medicare PIN