Healthcare Provider Details

I. General information

NPI: 1740574268
Provider Name (Legal Business Name): QUEEN TANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12520 WESTHEIMER RD A-1 #201 2307
HOUSTON TX
77077-5567
US

IV. Provider business mailing address

234 MEYER ST
SEALY TX
77474-2325
US

V. Phone/Fax

Practice location:
  • Phone: 832-786-9518
  • Fax:
Mailing address:
  • Phone: 832-786-9518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: