Provider Demographics
NPI:1053736710
Name:SANDRIDGE, CHRISTINE M
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:SANDRIDGE
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 1:6783 TERRY CHASE
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1448
Mailing Address - Country:US
Mailing Address - Phone:662-209-9219
Mailing Address - Fax:
Practice Address - Street 1:6783 TERRY CHASE
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1448
Practice Address - Country:US
Practice Address - Phone:662-209-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X
MS269971164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities