Basic Information
| Provider Information | |||||||||
| NPI: | 1235226069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CRISTIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CERTIFIED MEDICAL AS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PFEIFFER | ||||||||
| OtherFirstName: | CRISTIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CERTIFIED MEDICAL AS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | REA CLINIC | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 GAS PLANT RD | ||||||||
| Address2: | REA CLINIC DU QUOIN | ||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187248702 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.