Healthcare Provider Details

I. General information

NPI: 1629368212
Provider Name (Legal Business Name): DANLEE QUINLIVAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

4005 CHAMBERLAIN AVE
GULFPORT MS
39507-3914
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax:
Mailing address:
  • Phone: 251-753-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPTA4045
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: