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General NPI Number Information
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NPI Number | 1962862094
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Entity Type | Individual
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Provider Name | QUINN WILEY MPM, ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 03/02/2016
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Last Update Date | 03/02/2016
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Provider Practice Location Address
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Address Line | 11130 PARKVIEW CIRCLE DR
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City | FORT WAYNE
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State | IN
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Zip | 46845-1735
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Country | US
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Telephone | 260-578-0685
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Fax |
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Provider Business Mailing Address
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Address Line | 5151 E 1300 N
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City | NORTH MANCHESTER
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State | IN
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Zip | 46962-8260
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Country | US
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Telephone | 260-578-0685
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36002122A
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License Number State | IN
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