Provider Demographics
NPI:1982913091
Name:WILLEY, CYNTHIA JEAN
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:JEAN
Last Name:WILLEY
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 1:35318 RIVERWOOD TR
Mailing Address - Street 2:
Mailing Address - City:CROSS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442
Mailing Address - Country:US
Mailing Address - Phone:218-692-2022
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE N
Practice Address - Street 2:
Practice Address - City:ROTHSAY
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-948-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL70332-3164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse