Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant |
NPI | 1023521416 |
---|---|
Provider Name | Sarah Kay Childress |
First Address | Fordyce, AR 71742-3765 |
Second Address | Fordyce, AR 71742-3765 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2017 |
Last Update Date | 08/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
916585939 | DRIVER'S LICENSE (01) | AR |