Provider Demographics
NPI:1710211768
Name:CHILDRESS, ANDREA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3377 RIVERBEND DRIVE
Mailing Address - Street 2:PEACEHEALTH HOSPITAL MEDICINE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8803
Mailing Address - Country:US
Mailing Address - Phone:541-222-6389
Mailing Address - Fax:541-222-6385
Practice Address - Street 1:3377 RIVERBEND DRIVE
Practice Address - Street 2:PEACEHEALTH HOSPITAL MEDICINE
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-6389
Practice Address - Fax:541-222-6385
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60097977363L00000X, 363LA2200X, 363LG0600X
OR201250121NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006125438Medicaid