Provider Demographics
NPI:1841320959
Name:CHILDERS, DIANE LYNN (APRN, BC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4318
Mailing Address - Country:US
Mailing Address - Phone:618-344-7770
Mailing Address - Fax:
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-454-8134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN084174363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health