Healthcare Provider Details

I. General information

NPI: 1851866396
Provider Name (Legal Business Name): CHRISTOPHER CHILDERS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N ADELAIDE ST STE 102
FENTON MI
48430-2670
US

IV. Provider business mailing address

4160 JOHN R ST STE 930
DETROIT MI
48201-2017
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-7030
  • Fax: 810-208-0363
Mailing address:
  • Phone: 313-745-7247
  • Fax: 313-993-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704250115
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: