Healthcare Provider Details

I. General information

NPI: 1912343906
Provider Name (Legal Business Name): LA QUINN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 JACKSONVILLE DR
JACKSONVILLE BEACH FL
32250-3812
US

IV. Provider business mailing address

484 JACKSONVILLE DR
JACKSONVILLE BEACH FL
32250-3812
US

V. Phone/Fax

Practice location:
  • Phone: 904-595-5980
  • Fax: 904-595-5985
Mailing address:
  • Phone: 904-595-5980
  • Fax: 904-595-5985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberME94947
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME94947
License Number StateFL

VIII. Authorized Official

Name: DR. LINDA A QUINN
Title or Position: OWNER
Credential: M.D.
Phone: 904-595-5980