Provider Demographics
NPI:1700360914
Name:MAYBERRY, CHRISTINA (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:MAYBERRY
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 1:130 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1439
Mailing Address - Country:US
Mailing Address - Phone:618-263-3873
Mailing Address - Fax:
Practice Address - Street 1:130 W 7TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1439
Practice Address - Country:US
Practice Address - Phone:618-263-3873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL-162013163WL0100X
IL041467744163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant