Provider Demographics
NPI:1770983785
Name:CHILDRESS, LISA A (FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 COUNTY ROAD 17
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-7693
Mailing Address - Country:US
Mailing Address - Phone:740-646-5517
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:400 E STATE ST STE D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1870
Practice Address - Country:US
Practice Address - Phone:740-326-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV71599363L00000X
KY3015890363LF0000X
OHAPRN.CNP.022616363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV4606D629Medicare PIN
WVWV4606C447Medicare PIN