Provider Demographics
NPI:1245393693
Name:BERRY, CECILE (PA)
Entity Type:Individual
Prefix:
First Name:CECILE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CECILE
Other - Middle Name:D
Other - Last Name:BENOIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 SIMSBURY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3793
Mailing Address - Country:US
Mailing Address - Phone:860-284-5111
Mailing Address - Fax:860-284-5114
Practice Address - Street 1:100 SIMSBURY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3793
Practice Address - Country:US
Practice Address - Phone:860-284-5111
Practice Address - Fax:860-284-5114
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000230363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400090705Medicare PIN
S75132Medicare UPIN