Provider Demographics
NPI:1245842350
Name:DEFOREST, CHRISTINE LYNN (LPN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LYNN
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6644 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-8789
Mailing Address - Country:US
Mailing Address - Phone:607-437-1749
Mailing Address - Fax:
Practice Address - Street 1:6644 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-8789
Practice Address - Country:US
Practice Address - Phone:607-437-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303186-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNONEMedicaid