Provider Demographics
NPI:1801359575
Name:CHILDERS, KRISTIN ANNE (FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ANNE
Other - Last Name:KILPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 959203
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2000
Mailing Address - Country:US
Mailing Address - Phone:618-619-3330
Mailing Address - Fax:618-619-3385
Practice Address - Street 1:5213 GODFREY RD STE 110
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2510
Practice Address - Country:US
Practice Address - Phone:618-619-3330
Practice Address - Fax:618-619-3385
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20901908363L00000X
IL209.019081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty