Provider Demographics
NPI:1982208708
Name:FRED, CHRISTINA LYNN
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LYNN
Last Name:FRED
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 1:314 E COLE ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-2161
Mailing Address - Country:US
Mailing Address - Phone:618-318-2421
Mailing Address - Fax:
Practice Address - Street 1:314 E COLE ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-2161
Practice Address - Country:US
Practice Address - Phone:618-318-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide