Provider Demographics
NPI:1104831460
Name:RICKENBACK, CHRISTINA FULTZ (APRN)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:FULTZ
Last Name:RICKENBACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE WILDWOOD MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426
Mailing Address - Country:US
Mailing Address - Phone:860-767-0168
Mailing Address - Fax:860-767-1803
Practice Address - Street 1:ONE WILDWOOD MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426
Practice Address - Country:US
Practice Address - Phone:860-767-0168
Practice Address - Fax:860-767-1803
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000028363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
500000833Medicare ID - Type Unspecified
P11996Medicare UPIN