Provider Demographics
NPI:1235355819
Name:CHILDS, LAURIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:CHILDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12340 S 450 E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8154
Mailing Address - Country:US
Mailing Address - Phone:801-501-9797
Mailing Address - Fax:
Practice Address - Street 1:12340 S 450 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8154
Practice Address - Country:US
Practice Address - Phone:801-501-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6492794-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical