Provider Demographics
NPI:1891417325
Name:CHILDERS, TARA (RN, BSN, CCRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:RN, BSN, CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7403
Mailing Address - Country:US
Mailing Address - Phone:904-887-7174
Mailing Address - Fax:
Practice Address - Street 1:165 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7403
Practice Address - Country:US
Practice Address - Phone:904-887-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-177912163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse