Healthcare Provider Details

I. General information

NPI: 1770050122
Provider Name (Legal Business Name): THERESA QUEDNAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 CROSSING CT STE B
CHAMPAIGN IL
61822-5900
US

IV. Provider business mailing address

2916 CROSSING CT STE B
CHAMPAIGN IL
61822-5900
US

V. Phone/Fax

Practice location:
  • Phone: 217-693-7085
  • Fax:
Mailing address:
  • Phone: 217-693-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number3291
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberEH018812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: