Provider Demographics
NPI:1437955614
Name:GRISSOM, CHRISTINE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:LILBOURN
Mailing Address - State:MO
Mailing Address - Zip Code:63862-0145
Mailing Address - Country:US
Mailing Address - Phone:573-703-4107
Mailing Address - Fax:
Practice Address - Street 1:7570 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-9183
Practice Address - Country:US
Practice Address - Phone:573-703-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver