Basic Information
| Provider Information | |||||||||
| NPI: | 1114370137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDRE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANGELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 PA JOHNS RD NE | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310619070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784548255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 134 W CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310613639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784455288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2016 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN125490 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.