Provider Demographics
NPI:1316509334
Name:CHILDRESS, JAMES CLARK
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CLARK
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 FARMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0743
Mailing Address - Country:US
Mailing Address - Phone:931-644-2463
Mailing Address - Fax:
Practice Address - Street 1:457 VISTA DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1360
Practice Address - Country:US
Practice Address - Phone:931-738-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26091363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care