Healthcare Provider Details

I. General information

NPI: 1124301247
Provider Name (Legal Business Name): KATY MAY ALLEN QUACKENBUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATY MAY ALLEN

II. Dates (important events)

Enumeration Date: 09/25/2011
Last Update Date: 09/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SAWGRASS CORPORATE PKWY SUITE 106
SUNRISE FL
33325-6244
US

IV. Provider business mailing address

209 N FT LAUDERDALE BCH BLVD APARTMENT 10D
FORT LAUDERDALE FL
33304-4365
US

V. Phone/Fax

Practice location:
  • Phone: 954-745-1112
  • Fax: 954-745-1120
Mailing address:
  • Phone: 954-309-6129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI1999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: