Provider Demographics
NPI:1073816583
Name:CHILDERS, LACEE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LACEE
Middle Name:MARIE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LACEE
Other - Middle Name:MARIE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 79495
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0183
Mailing Address - Country:US
Mailing Address - Phone:951-788-3000
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3200
Practice Address - Fax:951-788-3200
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2013-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21251363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical