Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 0402205234 | VA |
NPI | 1013586650 |
---|---|
Provider Name | Christine Lorraine Hedblom |
First Address | Henrico, VA 23233-6989 |
Second Address | Henrico, VA 23233-3544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2021 |
Last Update Date | 18/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0402205234 | 0402205234 (01) | VA |