Healthcare Provider Details

I. General information

NPI: 1346731387
Provider Name (Legal Business Name): QUEENIE'S ANGELS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6355 27TH ST N
SAINT PETERSBURG FL
33702-6395
US

IV. Provider business mailing address

PO BOX 3392
PINELLAS PARK FL
33780-3392
US

V. Phone/Fax

Practice location:
  • Phone: 727-667-2184
  • Fax:
Mailing address:
  • Phone: 727-667-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAQUANDA SHAUNTA WHITAKER
Title or Position: OWNER
Credential:
Phone: 727-667-2184