Provider Demographics
NPI:1134315351
Name:HUMPHREY, CHRIS M
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:M
Last Name:HUMPHREY
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 1:410 EAGLE CT
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 EAGLE CT
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1575
Practice Address - Country:US
Practice Address - Phone:262-473-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29820-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39871900Medicaid