Healthcare Provider Details

I. General information

NPI: 1710211768
Provider Name (Legal Business Name): ANDREA LYNN CHILDRESS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DRIVE PEACEHEALTH HOSPITAL MEDICINE
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

3377 RIVERBEND DRIVE PEACEHEALTH HOSPITAL MEDICINE
SPRINGFIELD OR
97477-8803
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-6389
  • Fax: 541-222-6385
Mailing address:
  • Phone: 541-222-6389
  • Fax: 541-222-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60097977
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60097977
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60097977
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201250121NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: