Provider Demographics
NPI:1205357803
Name:DECKER, CHRISTINE ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:DECKER
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 1:9914 E ML AVE
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-8723
Mailing Address - Country:US
Mailing Address - Phone:269-598-7923
Mailing Address - Fax:269-665-5007
Practice Address - Street 1:9914 E ML AVE
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-8723
Practice Address - Country:US
Practice Address - Phone:269-598-7923
Practice Address - Fax:269-665-5007
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF390384856251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAF390384856OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS