Provider Demographics
NPI:1851458038
Name:CHILDRENS MEDICAL CENTER DALLAS
Entity type:Organization
Organization Name:CHILDRENS MEDICAL CENTER DALLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DETAMORE
Authorized Official - Last Name:ATHRE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN CPNP
Authorized Official - Phone:214-456-5614
Mailing Address - Street 1:5060 WATEKA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-4825
Mailing Address - Country:US
Mailing Address - Phone:214-353-2775
Mailing Address - Fax:214-456-5071
Practice Address - Street 1:1935 MOTOR ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-5614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630600282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren