Provider Demographics
NPI:1295473320
Name:MORTIMER, CHRISTINIA LYINN-MARIE (LPN)
Entity type:Individual
Prefix:
First Name:CHRISTINIA
Middle Name:LYINN-MARIE
Last Name:MORTIMER
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 1:583 SOUTHLAKE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3096
Mailing Address - Country:US
Mailing Address - Phone:540-903-8090
Mailing Address - Fax:
Practice Address - Street 1:13640 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:NY
Practice Address - Zip Code:12029-3506
Practice Address - Country:US
Practice Address - Phone:607-422-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331502164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse