Provider Demographics
NPI:1649995747
Name:PROVOST, CHRISTINE LESLIE (RN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LESLIE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 JAMES MOORE CIR
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9416
Mailing Address - Country:US
Mailing Address - Phone:585-355-3149
Mailing Address - Fax:
Practice Address - Street 1:1099 JAY ST BLDG P
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-1164
Practice Address - Country:US
Practice Address - Phone:585-325-3580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY722626163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse