1962766410 NPI number — CHRISTINA MARIE VAN GENNEP ARNP

Table of content: CHRISTINA MARIE VAN GENNEP ARNP (NPI 1962766410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962766410 NPI number — CHRISTINA MARIE VAN GENNEP ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GENNEP
Provider First Name:
CHRISTINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARRERA
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962766410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7027 HUGH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32404-8420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1108 ROSS CLARK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-8941
Provider Business Practice Location Address Fax Number:
334-793-8093
Provider Enumeration Date:
06/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0000X , with the licence number:  1-181102 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: ARNP9262470 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005969200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y0AU7 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101035300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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