Basic Information
| Provider Information | |||||||||
| NPI: | 1083035026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDS | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | RDMS, RVT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PSC 251 BOX 139 | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 965420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6714888749 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 ROAD 535 | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026296611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471S1302X | 140721 | DE | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Sonography | 2471V0105X | 140721 | DE | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Vascular Sonography |
ID Information
| ID | Type | State | Issuer | Description | 012325041-01 | 01 | GU | TRICARE | OTHER |