Provider Demographics
NPI:1467148544
Name:CHILDRESS, DERRICK LAMONT
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LAMONT
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 NEW INGRAM RD APT B
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-5156
Mailing Address - Country:US
Mailing Address - Phone:434-713-6375
Mailing Address - Fax:
Practice Address - Street 1:145 NEW INGRAM RD APT B
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-5156
Practice Address - Country:US
Practice Address - Phone:434-713-6375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker