Healthcare Provider Details

I. General information

NPI: 1508176397
Provider Name (Legal Business Name): TYNIA CHILDS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 W BROADWAY APT 7K
MONTICELLO NY
12701-7154
US

IV. Provider business mailing address

55 GRASSY SPRINGS CT
OXFORD GA
30054-3012
US

V. Phone/Fax

Practice location:
  • Phone: 845-428-5554
  • Fax:
Mailing address:
  • Phone: 470-314-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number322787
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: