Healthcare Provider Details

I. General information

NPI: 1386368736
Provider Name (Legal Business Name): MARK EDWARD CHILDRESS DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MCCALLIE AVE
CHATTANOOGA TN
37404-3258
US

IV. Provider business mailing address

931 POLO PL
CHATTANOOGA TN
37405-3041
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-6061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number32473
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32473
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: