Provider Demographics
NPI:1083966246
Name:CHILDRESS, KATHRYN L (PAAA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:L
Other - Last Name:ECKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:PO BOX 603484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3484
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-402-1436
Practice Address - Fax:843-402-1833
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006603367H00000X
SC86367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023I23439Medicare PIN