Provider Demographics
NPI:1841502259
Name:CHILDERS, EMILY WYN (LMT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:WYN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 FIRESIDE RD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9557
Mailing Address - Country:US
Mailing Address - Phone:352-321-0332
Mailing Address - Fax:
Practice Address - Street 1:2180 FIRESIDE RD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-9557
Practice Address - Country:US
Practice Address - Phone:352-321-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58910174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist