Provider Demographics
NPI:1063212579
Name:CHILDERS, NICHOLAS W
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:W
Last Name:CHILDERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20530 COLONIAL ISLE DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3701
Mailing Address - Country:US
Mailing Address - Phone:407-516-7419
Mailing Address - Fax:
Practice Address - Street 1:20530 COLONIAL ISLE DR UNIT 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3701
Practice Address - Country:US
Practice Address - Phone:407-516-7419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program