Provider Demographics
NPI:1689241333
Name:LANDON, CHRISTINE BROCK (RN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:BROCK
Last Name:LANDON
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 1:6112 PINEY BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-6173
Mailing Address - Country:US
Mailing Address - Phone:901-232-7557
Mailing Address - Fax:
Practice Address - Street 1:6112 PINEY BLUFF RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-6173
Practice Address - Country:US
Practice Address - Phone:901-232-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3965376G00000X
AR092816163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARR092816OtherREGISTERED LICENSE NUMBER