Provider Demographics
NPI:1518382134
Name:CHILDE, AUTUMN (LMP)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:CHILDE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16804 S MALLOY PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-5052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1951 1ST ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-2000
Practice Address - Country:US
Practice Address - Phone:509-235-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60238003111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor