Provider Demographics
NPI:1104827492
Name:CHILDRESS, MULLISSA MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:MULLISSA
Middle Name:MICHELLE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:APRN
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5088
Mailing Address - Fax:
Practice Address - Street 1:8680 W CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7458
Practice Address - Country:US
Practice Address - Phone:702-877-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-11-04
Deactivation Date:2006-05-26
Deactivation Code:
Reactivation Date:2014-08-14
Provider Licenses
StateLicense IDTaxonomies
OHF0714788363LF0000X
OH16446-NP363LP2300X
NVAPRN002193363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113011Medicaid
OH0129662Medicaid
OHH326620Medicare UPIN
OH0113011Medicaid