Provider Demographics
NPI:1174038145
Name:CHILDERS, SHELLY STEWART
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:STEWART
Last Name:CHILDERS
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 1:4700 WATERS AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2700
Mailing Address - Fax:912-350-2715
Practice Address - Street 1:4700 WATERS AVE STE 405
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-2700
Practice Address - Fax:912-350-2715
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA216525363LP2300X
GARN216525363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care