Provider Demographics
NPI:1104225572
Name:UMEUGO, CECRYSTAL
Entity type:Individual
Prefix:
First Name:CECRYSTAL
Middle Name:
Last Name:UMEUGO
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 1:5 SHORTELL DR
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2402
Mailing Address - Country:US
Mailing Address - Phone:203-906-6486
Mailing Address - Fax:
Practice Address - Street 1:5 SHORTELL DRIVE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2402
Practice Address - Country:US
Practice Address - Phone:203-906-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5879363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily