=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801359575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN ANNE CHILDERS FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2019
-----------------------------------------------------
Last Update Date | 09/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5213 GODFREY RD STE 110
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-619-3330
-----------------------------------------------------
Fax | 618-619-3385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 959203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63195-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-619-3330
-----------------------------------------------------
Fax | 618-619-3385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209.019081
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 20901908
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------