Provider Demographics
NPI:1679017925
Name:CLANCY, CHRISTINA L (CNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:L
Last Name:CLANCY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9694
Mailing Address - Country:US
Mailing Address - Phone:262-249-4660
Mailing Address - Fax:262-249-7128
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147
Practice Address - Country:US
Practice Address - Phone:262-249-4660
Practice Address - Fax:262-249-7128
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019992363LF0000X
IL209017362363LF0000X
WI9353363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092173Medicaid