Healthcare Provider Details

I. General information

NPI: 1588553283
Provider Name (Legal Business Name): LARRY WAYNE CHILDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 BALL PARK RD
HARLAN KY
40831-1701
US

IV. Provider business mailing address

37 BALL PARK RD
HARLAN KY
40831-1701
US

V. Phone/Fax

Practice location:
  • Phone: 606-573-4520
  • Fax: 606-573-6392
Mailing address:
  • Phone: 606-573-4520
  • Fax: 606-573-6392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4042781
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: