Provider Demographics
NPI:1538761465
Name:CHILDRESS, PAIGE LYNN (CF-M)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:LYNN
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:CF-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 N DIXIE FWY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6069
Mailing Address - Country:US
Mailing Address - Phone:386-427-6344
Mailing Address - Fax:855-250-9392
Practice Address - Street 1:1131 N DIXIE FWY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA
Practice Address - State:FL
Practice Address - Zip Code:32168-6069
Practice Address - Country:US
Practice Address - Phone:386-427-6344
Practice Address - Fax:855-250-9392
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CFM03368224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CFM03368OtherCERTIFIED FITTER-MASTECTOMY