Provider Demographics
NPI:1376920033
Name:PROUD, CHRISTA JEAN (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHRISTA
Middle Name:JEAN
Last Name:PROUD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CHRISTA
Other - Middle Name:JEAN
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2001-32ND STREET
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-2208
Mailing Address - Country:US
Mailing Address - Phone:262-515-6771
Mailing Address - Fax:
Practice Address - Street 1:2001-32ND STREET
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-2208
Practice Address - Country:US
Practice Address - Phone:262-515-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305156-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse