Provider Demographics
NPI:1336911262
Name:GANN, CHRISTINE J
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:J
Last Name:GANN
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 182
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74602-0182
Mailing Address - Country:US
Mailing Address - Phone:580-686-0202
Mailing Address - Fax:
Practice Address - Street 1:1815 N UNION ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2440
Practice Address - Country:US
Practice Address - Phone:580-686-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK134600175T00000X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No175T00000XOther Service ProvidersPeer Specialist