Provider Demographics
NPI:1598211849
Name:CHILDRESS, SEDREK (CERTIFIED NUTRITIONI)
Entity Type:Individual
Prefix:
First Name:SEDREK
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:CERTIFIED NUTRITIONI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 SOHO ST SUITE 101
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835
Mailing Address - Country:US
Mailing Address - Phone:574-903-3965
Mailing Address - Fax:
Practice Address - Street 1:3406 SOHO ST APT 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-7593
Practice Address - Country:US
Practice Address - Phone:574-903-3965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL79170132700000X, 133N00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133N00000XDietary & Nutritional Service ProvidersNutritionist