Provider Demographics
NPI:1083966246
Name:CHILDRESS, KATHRYN L (PAAA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:L
Other - Last Name:ECKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:3155 N POINT PKWY STE F100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5495
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:770-645-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006603367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023I23439Medicare PIN