MEDICARE: MICAH LEON CHILDRESS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	TEMP897150	NV
2	363LA2100X	Acute Care Nurse Practitioner	1138148	TX
3	363LA2100X	Acute Care Nurse Practitioner	333548	AZ
4	363LA2100X	Acute Care Nurse Practitioner	95027332	CA
5	363LA2100X	Acute Care Nurse Practitioner	10055339	OR

General Provider Information

NPI Number	:	1063291847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAH LEON CHILDRESS NP

Provider Business Mailing Address
First Line	:	1331 LARKSPUR DR
Second Line	:
City	:	ROCKLIN
State	:	CA
Zip	:	95765-5593
Country	:	US
Telephone Number	:	903-918-3016
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340 SUNSET BLVD #100
Second Line	:	STUDIO 23
City	:	ROCKLIN
State	:	CA
Zip	:	95765
Country	:	US
Telephone Number	:	903-918-3016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	01/20/2026

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