Healthcare Provider Details

I. General information

NPI: 1013379056
Provider Name (Legal Business Name): KEONA CHILDS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

1800 N CALIFORNIA ST
STOCKTON CA
95204-6019
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4575
  • Fax: 414-955-6528
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA168870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: