Basic Information
| Provider Information | |||||||||
| NPI: | 1801091103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88 | ||||||||
| Address2: | 5 E ALVON ROAD SUITE 7 | ||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249862373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 1ST AVE | ||||||||
| Address2: | ROOM 1025 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997484 | ||||||||
| FaxNumber: | 3043997579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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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 | 43022 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 43022 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7101002000 | 05 | WV | MEDICAID | 2772790 | 05 | OH | MEDICAID | 7100123630 | 05 | KY | MEDICAID | P00851933 | 01 | WV | RR MEDICARE | OTHER |