Provider Demographics
NPI:1215068549
Name:CHILDERS, REBECCA LYNN (PA)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LYNN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:530 E THOMAS ROAD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3204
Mailing Address - Country:US
Mailing Address - Phone:860-678-3402
Mailing Address - Fax:844-364-3181
Practice Address - Street 1:22711 S ELLSWORTH ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142
Practice Address - Country:US
Practice Address - Phone:480-782-0993
Practice Address - Fax:833-337-0386
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2021-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE1293363A00000X
AZ2760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100250445-00Medicaid
NE100250445-00Medicaid