Provider Demographics
NPI:1871148528
Name:CHILDERS, KELLY JO (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1475 EAST LIBERTY STREET
Mailing Address - Street 2:P.O. BOX 770
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-0770
Mailing Address - Country:US
Mailing Address - Phone:803-684-1905
Mailing Address - Fax:803-684-1907
Practice Address - Street 1:1010 DEVINNEY RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-2127
Practice Address - Country:US
Practice Address - Phone:803-684-6159
Practice Address - Fax:803-684-1916
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC205860163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC205860OtherBOARD OF NURSING