=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720024318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE ANN QUANDT RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13705 W GREEN MEADOW DR
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53151-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-617-5318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4217 S PACKARD AVE
-----------------------------------------------------
City | ST FRANCIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53235-5543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-481-3640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 97876030
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------