Provider Demographics
NPI:1689370728
Name:CHILDRESS, BEVERLY MICHELLE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:MICHELLE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 WESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7100
Mailing Address - Country:US
Mailing Address - Phone:757-322-0850
Mailing Address - Fax:
Practice Address - Street 1:6528 WESTBROOK DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7100
Practice Address - Country:US
Practice Address - Phone:757-322-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA60316370343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)