Provider Demographics
NPI:1508176397
Name:CHILDS, TYNIA (LPN)
Entity Type:Individual
Prefix:MS
First Name:TYNIA
Middle Name:
Last Name:CHILDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 W BROADWAY APT 7K
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-7154
Mailing Address - Country:US
Mailing Address - Phone:845-428-5554
Mailing Address - Fax:
Practice Address - Street 1:685 W BROADWAY APT 7K
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7154
Practice Address - Country:US
Practice Address - Phone:845-428-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300685164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1508176397Medicaid