Provider Demographics
NPI:1083249429
Name:TAKO, CECILIA EBAI (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:CECILIA
Middle Name:EBAI
Last Name:TAKO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13206 OYSTERCATCHER LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4766
Mailing Address - Country:US
Mailing Address - Phone:240-565-8977
Mailing Address - Fax:
Practice Address - Street 1:915 ELLA T GRASSO BLVD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-5516
Practice Address - Country:US
Practice Address - Phone:561-444-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207210163W00000X
MDR187498363LP0808X
VA0024186692363LP0808X
FLAPRN11015301363LP0808X
CT011979363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty