Provider Demographics
NPI:1548737935
Name:CHILDRESS, STEPHANIE M (FNP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:FNP-C
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 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:232-826-9404
Practice Address - Street 1:316 MARKETPLACE BLVD STE 20
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2596
Practice Address - Country:US
Practice Address - Phone:423-794-5580
Practice Address - Fax:423-232-8561
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily