Provider Demographics
NPI:1710380183
Name:WITHERS, CHRISTINE DIANA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:DIANA
Last Name:WITHERS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 E. 9TH STREET NORTH
Mailing Address - Street 2:BLDG 4970, ROOM 123
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:912-435-1383
Mailing Address - Fax:912-435-6133
Practice Address - Street 1:703 E. 9TH STREET NORTH
Practice Address - Street 2:BLDG 4970, ROOM 123
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-1383
Practice Address - Fax:912-435-6133
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC78213163WC0400X
GARN150190163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management