Healthcare Provider Details

I. General information

NPI: 1124889407
Provider Name (Legal Business Name): CHRISTINA DIANE GARNER CHW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 E SPRINGFIELD RD
SULLIVAN MO
63080-1311
US

IV. Provider business mailing address

153 E SPRINGFIELD RD
SULLIVAN MO
63080-1311
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-4777
  • Fax: 573-468-4757
Mailing address:
  • Phone: 573-468-4777
  • Fax: 573-468-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2021003337
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number17265
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: