Provider Demographics
NPI:1609179894
Name:DEA, CHRISTINA A
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:A
Last Name:DEA
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 1:18117 DICKENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-1763
Mailing Address - Country:US
Mailing Address - Phone:941-276-4937
Mailing Address - Fax:
Practice Address - Street 1:18117 DICKENS AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-1763
Practice Address - Country:US
Practice Address - Phone:941-276-4937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0005232003747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000523200Medicaid