Provider Demographics
NPI:1871697342
Name:EBELACKER, CYNTHIA ALLEN (ANP)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:ALLEN
Last Name:EBELACKER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10251 STEWART DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9509
Mailing Address - Country:US
Mailing Address - Phone:907-696-2493
Mailing Address - Fax:
Practice Address - Street 1:1407 W 31ST AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3678
Practice Address - Country:US
Practice Address - Phone:907-646-9948
Practice Address - Fax:907-646-9949
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123065163W00000X
AK435363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP04351Medicaid
AKNP04357Medicaid