=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235843079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNA QUELLER MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2023
-----------------------------------------------------
Last Update Date | 01/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 W PALMETTO PARK RD STE 105
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-783-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3179 SAINT ANNES DR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-560-8790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/OWNER
-----------------------------------------------------
Name | DR. JENNA NATALIE QUELLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-783-3376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------