Provider Demographics
NPI:1336683192
Name:STATOM, CHRISTINE A (LPN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:STATOM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10457 HIGHWAY 221 S
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:SC
Mailing Address - Zip Code:29384-3910
Mailing Address - Country:US
Mailing Address - Phone:864-677-4670
Mailing Address - Fax:864-677-4674
Practice Address - Street 1:10457 HIGHWAY 221 S
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:SC
Practice Address - Zip Code:29384-3910
Practice Address - Country:US
Practice Address - Phone:864-677-4670
Practice Address - Fax:864-677-4674
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP39793164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse