Healthcare Provider Details

I. General information

NPI: 1336874700
Provider Name (Legal Business Name): ANNA NICOLE QUILLEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE BLDG 3
ROCHESTER NY
14621-3095
US

IV. Provider business mailing address

1425 PORTLAND AVE BLDG 3
ROCHESTER NY
14621-3095
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number1972090
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: