Healthcare Provider Details

I. General information

NPI: 1194283879
Provider Name (Legal Business Name): DEMETRA CHILDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81555 JFK CT
INDIO CA
92201-7726
US

IV. Provider business mailing address

81555 JFK CT
INDIO CA
92201-7726
US

V. Phone/Fax

Practice location:
  • Phone: 760-262-1017
  • Fax: 760-262-1017
Mailing address:
  • Phone: 760-262-1017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: