Provider Demographics
NPI:1568084341
Name:MAKOUMBOU, CRYDEGE (RN)
Entity Type:Individual
Prefix:
First Name:CRYDEGE
Middle Name:
Last Name:MAKOUMBOU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 N WINOOSKI AVE UNIT 15
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3956
Mailing Address - Country:US
Mailing Address - Phone:802-881-6740
Mailing Address - Fax:
Practice Address - Street 1:343 N WINOOSKI AVE UNIT 15
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3956
Practice Address - Country:US
Practice Address - Phone:802-881-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0067250163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse