Provider Demographics
NPI:1851913883
Name:HUMBER, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:HUMBER
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 1:48 WILDEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1838
Mailing Address - Country:US
Mailing Address - Phone:914-602-5179
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR STE LL105
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1845300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist