Provider Demographics
NPI:1215936315
Name:CAINE, CYNTHIA R (FNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:CAINE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8208
Mailing Address - Country:US
Mailing Address - Phone:708-873-0062
Mailing Address - Fax:708-873-1820
Practice Address - Street 1:11200 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8208
Practice Address - Country:US
Practice Address - Phone:708-873-0062
Practice Address - Fax:708-873-1820
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000102A363LF0000X
IL209006990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200062090Medicaid
INP00058964OtherTRAVELERS MCR PROVIDER #
ILR00585Medicare PIN
IN200062090Medicaid
ILR00584Medicare PIN
IN659650FMedicare ID - Type Unspecified