Provider Demographics
NPI:1679211569
Name:CHILDRESS, NOLAN DEWITT JR
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:DEWITT
Last Name:CHILDRESS
Suffix:JR
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 1:5197 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1403
Mailing Address - Country:US
Mailing Address - Phone:216-538-9010
Mailing Address - Fax:
Practice Address - Street 1:5197 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1403
Practice Address - Country:US
Practice Address - Phone:216-538-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-22
Last Update Date:2022-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant