Provider Demographics
NPI:1376114017
Name:CLARK-BUMGARNER, CYNTHIA JUNE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JUNE
Last Name:CLARK-BUMGARNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:JUNE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 5-704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-926-8369
Mailing Address - Fax:312-926-8341
Practice Address - Street 1:251 E HURON ST STE 5-704
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-8369
Practice Address - Fax:312-926-8341
Is Sole Proprietor?:No
Enumeration Date:2021-07-04
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022005931367500000X
IL209025457367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered