Provider Demographics
NPI:1255047270
Name:SOUTHERS, CHRISTINA (MASTERS BOARD CERT)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:SOUTHERS
Suffix:
Gender:F
Credentials:MASTERS BOARD CERT
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:RENEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PARAMEDICAL TATTOOER
Mailing Address - Street 1:3511 BELLBLUFF DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:587 SOUTHLAKE BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3096
Practice Address - Country:US
Practice Address - Phone:804-895-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical