Provider Demographics
NPI:1427696335
Name:FITZGERALD, CECILE WRIGHT
Entity type:Individual
Prefix:
First Name:CECILE
Middle Name:WRIGHT
Last Name:FITZGERALD
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:PO BOX 3343
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12837 MARTINSVILLE HWY LOT 19
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:VA
Practice Address - Zip Code:24069-3548
Practice Address - Country:US
Practice Address - Phone:276-340-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT66806501172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver