Healthcare Provider Details

I. General information

NPI: 1710202114
Provider Name (Legal Business Name): QUEEN CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 FAIRWAY RUN
FORSYTH GA
31029-4975
US

IV. Provider business mailing address

380 HOSPITAL DR STE 350
MACON GA
31217-8001
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-3937
  • Fax:
Mailing address:
  • Phone: 478-742-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number057437
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number057437
License Number StateGA

VIII. Authorized Official

Name: ANIKA G BRADLEY
Title or Position: OWNER
Credential: MD
Phone: 478-742-3937