Healthcare Provider Details

I. General information

NPI: 1710039425
Provider Name (Legal Business Name): JENNIFER ANN MCQUILLEN LNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7735 FARR ST APT 602
DANIEL ISLAND SC
29492-6405
US

IV. Provider business mailing address

7735 FARR ST APT 602
DANIEL ISLAND SC
29492-6405
US

V. Phone/Fax

Practice location:
  • Phone: 540-336-8512
  • Fax:
Mailing address:
  • Phone: 540-336-8512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0017000701
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0017000701
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: