Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | R030792 | ME |
NPI | 1619161346 |
---|---|
Provider Name | Kathleen Childs |
First Address | Newport, ME 04953-4055 |
Second Address | Dover Foxcroft, ME 04426-3742 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2007 |
Last Update Date | 06/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MC1389382 | DEA (01) | ME |