Provider Demographics
NPI:1124562178
Name:DODGE, CHRISTINE ANN (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:DODGE
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 1:71479 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9129
Mailing Address - Country:US
Mailing Address - Phone:701-238-8464
Mailing Address - Fax:
Practice Address - Street 1:2627 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5975
Practice Address - Country:US
Practice Address - Phone:701-238-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704316285163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health