Provider Demographics
NPI:1114370137
Name:CHILDRE, MARY ANGELA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELA
Last Name:CHILDRE
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 1:160 PA JOHNS RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9070
Mailing Address - Country:US
Mailing Address - Phone:478-454-8255
Mailing Address - Fax:
Practice Address - Street 1:134 W CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3639
Practice Address - Country:US
Practice Address - Phone:478-445-5288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN125490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily