Basic Information
| Provider Information | |||||||||
| NPI: | 1801837588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDRESS | ||||||||
| FirstName: | ELSIE | ||||||||
| MiddleName: | SHARON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHANCEY HAWKINS | ||||||||
| OtherFirstName: | ELSIE | ||||||||
| OtherMiddleName: | SHARON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1006 W PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | AVON PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634533121 | ||||||||
| FaxNumber: | 8633821433 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 W PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | AVON PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634533121 | ||||||||
| FaxNumber: | 8633821433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | ARNP1701242 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.