Provider Demographics
NPI:1154068427
Name:BRANDENBURG, CHRISTINA MICHELLE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MICHELLE
Last Name:BRANDENBURG
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 1:205 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-1259
Mailing Address - Country:US
Mailing Address - Phone:606-596-0323
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1259
Practice Address - Country:US
Practice Address - Phone:606-596-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist