Provider Demographics
NPI:1982291589
Name:CHILDRESS, DONNETTA RENEE
Entity Type:Individual
Prefix:
First Name:DONNETTA
Middle Name:RENEE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 E 172ND ST # UP
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-3129
Mailing Address - Country:US
Mailing Address - Phone:216-333-7387
Mailing Address - Fax:
Practice Address - Street 1:1218 E 172ND ST # UP
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-3129
Practice Address - Country:US
Practice Address - Phone:216-333-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3037181251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health