Provider Demographics
NPI:1063483642
Name:MADDOX, CHRISTINE MARIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:FNP
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:8865 W 400 N STE 120
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9011
Practice Address - Country:US
Practice Address - Phone:219-878-5031
Practice Address - Fax:219-879-5498
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001740A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400035552OtherMEDICARE PTAN
IN201007040Medicaid
IN000001078424OtherANTHEM BCBS
IN201007040Medicaid