Provider Demographics
NPI:1336483841
Name:CHILDERS, ANITA RAE (RD)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:RAE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:ANITA
Other - Middle Name:RAE
Other - Last Name:CONLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:MP 317
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-2418
Mailing Address - Fax:407-649-3187
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-2418
Practice Address - Fax:407-649-3187
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5649133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered