Provider Demographics
NPI:1255743373
Name:CHILDERS, MANDY (FNP-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:GEEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1832 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6311
Mailing Address - Country:US
Mailing Address - Phone:931-919-3833
Mailing Address - Fax:
Practice Address - Street 1:1832 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-919-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18681363LF0000X
KY3008712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK162730OtherMEDICARE