Provider Demographics
NPI:1467729632
Name:PERRY, CHRISTINA LEE (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LEE
Last Name:PERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:POLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:310 CHRISTIAN RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:NY
Mailing Address - Zip Code:12936-2406
Mailing Address - Country:US
Mailing Address - Phone:518-572-4448
Mailing Address - Fax:
Practice Address - Street 1:17 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-2616
Practice Address - Country:US
Practice Address - Phone:518-643-6442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306527-1164W00000X
NY665816163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPROPRIETORMedicaid