Healthcare Provider Details

I. General information

NPI: 1235797622
Provider Name (Legal Business Name): CHRISTINA HODGES RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W LAFAYETTE ST
VERSAILLES MO
65084-1346
US

IV. Provider business mailing address

104 W LAFAYETTE ST
VERSAILLES MO
65084-1346
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5438
  • Fax: 573-378-7375
Mailing address:
  • Phone: 573-378-5438
  • Fax: 573-378-7375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2010021891
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: