Provider Demographics
NPI:1508575713
Name:CHILDERS, JENNIFER ANN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 LINWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2369
Mailing Address - Country:US
Mailing Address - Phone:704-658-6048
Mailing Address - Fax:
Practice Address - Street 1:134 MEDICAL PARK RD STE 111
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8527
Practice Address - Country:US
Practice Address - Phone:704-801-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017238363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care