Provider Demographics
NPI:1316932734
Name:GORRELL, CYNTHIA K (NP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:K
Last Name:GORRELL
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7956 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-6722
Practice Address - Fax:260-435-6726
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2020-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71000946A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200201500Medicaid
IN200945140Medicaid
IN000000675816OtherANTHEM
IN200945140Medicaid
INM400025823Medicare PIN
IN194020BMedicare ID - Type Unspecified