Provider Demographics
NPI:1558390658
Name:CHILDERS, SHELIA KERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:KERESA
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA-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 634909
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 GROSS CRESCENT CIR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3643
Practice Address - Country:US
Practice Address - Phone:706-858-2161
Practice Address - Fax:865-560-7387
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00231570OtherRAILROAD MEDICARE
GA100002328DMedicaid
TNP00231570OtherBCBS OF TENNESSEE
TNP00231570OtherBCBS OF TENNESSEE
GAP00231570OtherRAILROAD MEDICARE