Provider Demographics
NPI:1588969182
Name:FRAZIER, CYNTHIA TIESE
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:TIESE
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-0179
Mailing Address - Country:US
Mailing Address - Phone:318-245-8287
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY # 71
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-466-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered