Provider Demographics
NPI:1306317904
Name:POPOVIC, CHRISTINA MARIE (NP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:POPOVIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:MARIE
Other - Last Name:DERIDDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3535 W 13 MILE RD STE 644
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:800-253-5592
Practice Address - Fax:248-551-2125
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289544363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care