Provider Demographics
NPI:1104528058
Name:CHILDS, VICTORIA EMILY
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:EMILY
Last Name:CHILDS
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 1:36 KITTREDGE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3540
Mailing Address - Country:US
Mailing Address - Phone:508-340-0695
Mailing Address - Fax:
Practice Address - Street 1:136 HARRISON AVE # M&V510
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1817
Practice Address - Country:US
Practice Address - Phone:508-340-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant