Provider Demographics
NPI:1902480270
Name:CHILDERS, TETYANA
Entity Type:Individual
Prefix:
First Name:TETYANA
Middle Name:
Last Name:CHILDERS
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 1:317 W 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-4915
Mailing Address - Country:US
Mailing Address - Phone:509-942-4395
Mailing Address - Fax:
Practice Address - Street 1:317 W 21ST AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-4915
Practice Address - Country:US
Practice Address - Phone:509-942-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty
No171W00000XOther Service ProvidersContractor