Healthcare Provider Details

I. General information

NPI: 1124677893
Provider Name (Legal Business Name): CHRISTINA IRENE PRINCE MSN, RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 06/03/2021
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 BASS RD
MACON GA
31210-7510
US

IV. Provider business mailing address

PO BOX 1894
PERRY GA
31069-1894
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-4494
  • Fax:
Mailing address:
  • Phone: 615-522-8421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number93502
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN293292
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number93502
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN293292
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number187027
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number187027
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: