Basic Information
| Provider Information | |||||||||
| NPI: | 1720142870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | JENEE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7687 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 BUSINESS LOOP 70 WEST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822587 | ||||||||
| FaxNumber: | 5738843037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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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 | 363L00000X | 2005033254 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 773636 | 01 | MO | HEALTHLINK | OTHER | 424582807 | 05 | MO | MEDICAID |