MEDICARE: NAKISHA LACHELLE CHILDERS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	5017899	NC
2	363LF0000X	Family Nurse Practitioner	5017899	NC

General Provider Information

NPI Number	:	1376239624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAKISHA LACHELLE CHILDERS FNP

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2090 S US 29 HWY
Second Line	:
City	:	CHINA GROVE
State	:	NC
Zip	:	28023-8650
Country	:	US
Telephone Number	:	704-403-6800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2023
Last Update Date	:	07/15/2024

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