MEDICARE: DEBRA RENEE QUEEN R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	1025	AR
2	133V00000X	Registered Dietitian	164.006191	IL
3	133V00000X	Registered Dietitian	LD718	OK

General Provider Information

NPI Number	:	1659423184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA RENEE QUEEN R.D.

Provider Business Mailing Address
First Line	:	109 CALIFORNIA ST
Second Line	:	PO BOX 577
City	:	CARTERVILLE
State	:	IL
Zip	:	62918
Country	:	US
Telephone Number	:	618-519-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 S LEWIS LN
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-3547
Country	:	US
Telephone Number	:	618-519-9200
Fax Number	:	618-519-9961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	10/11/2024

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