Provider Demographics
NPI:1063084952
Name:CHILDS, ANNETTA LYNNAE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:ANNETTA
Middle Name:LYNNAE
Last Name:CHILDS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 RAYNA ST
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12443-5222
Mailing Address - Country:US
Mailing Address - Phone:845-443-1280
Mailing Address - Fax:
Practice Address - Street 1:224 FAIR ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4561
Practice Address - Country:US
Practice Address - Phone:845-443-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
NY018655-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist