Provider Demographics
NPI:1588553283
Name:CHILDERS, LARRY WAYNE
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:CHILDERS
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 1:107 ELDRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:KY
Mailing Address - Zip Code:40823-1240
Mailing Address - Country:US
Mailing Address - Phone:606-369-1717
Mailing Address - Fax:
Practice Address - Street 1:107 ELDRIDGE RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:KY
Practice Address - Zip Code:40823-1240
Practice Address - Country:US
Practice Address - Phone:606-369-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4042781363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health