Provider Demographics
NPI:1366721490
Name:CHILDRESS, ANGELA NICOLE (DPT)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICOLE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CEDAR CREST DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3780
Mailing Address - Country:US
Mailing Address - Phone:417-531-1252
Mailing Address - Fax:
Practice Address - Street 1:331 HOSPITAL DR STE D
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9251
Practice Address - Country:US
Practice Address - Phone:417-533-6315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist