Basic Information
Provider Information | |||||||||
NPI: | 1417206350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDERS | ||||||||
FirstName: | ZESTA | ||||||||
MiddleName: | SHIRELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RAMSEY | ||||||||
OtherFirstName: | ZESTA | ||||||||
OtherMiddleName: | SHIRELLE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 640 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE RAPIDS | ||||||||
State: | NC | ||||||||
PostalCode: | 278700640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2525365000 | ||||||||
FaxNumber: | 2525365444 | ||||||||
Practice Location | |||||||||
Address1: | 919 JR HIGH SCHOOL RD | ||||||||
Address2: |   | ||||||||
City: | SCOTLAND NECK | ||||||||
State: | NC | ||||||||
PostalCode: | 278741219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528263143 | ||||||||
FaxNumber: | 2528263110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2012 | ||||||||
LastUpdateDate: | 02/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085004356 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-04588 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.