=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477150647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUIENNE WHITE MT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 RTE 22 STE 6
-----------------------------------------------------
City | BRANCHBURG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08876-3595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-704-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2038 ROY CT
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18040-8199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-667-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT00690600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------