Healthcare Provider Details

I. General information

NPI: 1689241333
Provider Name (Legal Business Name): CHRISTINE BROCK LANDON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 PINEY BLUFF RD
BARTLETT TN
38135-6173
US

IV. Provider business mailing address

6112 PINEY BLUFF RD
BARTLETT TN
38135-6173
US

V. Phone/Fax

Practice location:
  • Phone: 901-232-7557
  • Fax:
Mailing address:
  • Phone: 901-232-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number3965
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number092816
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: