Healthcare Provider Details

I. General information

NPI: 1366088064
Provider Name (Legal Business Name): HEATHER CHILDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 AGNES AVE
SANTA MARIA CA
93458-2838
US

IV. Provider business mailing address

116 AGNES AVE
SANTA MARIA CA
93458-2838
US

V. Phone/Fax

Practice location:
  • Phone: 805-457-3724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number275667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: