Provider Demographics
NPI:1689366056
Name:CHILDERS, EMILY NICOLE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2430
Practice Address - Country:US
Practice Address - Phone:336-527-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant