Healthcare Provider Details

I. General information

NPI: 1699825901
Provider Name (Legal Business Name): CHRISTINE LORRAINE BUMGARDNER APRN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15802 STATE ROUTE 104
CHILLICOTHEE OH
45601-9701
US

IV. Provider business mailing address

72 GULLETTE DR
CHILLICOTHEE OH
45601-9795
US

V. Phone/Fax

Practice location:
  • Phone: 740-774-7080
  • Fax:
Mailing address:
  • Phone: 740-774-4283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN. 183506
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberNS-03462
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCTP # RX. 03462
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: