Basic Information
| Provider Information | |||||||||
| NPI: | 1063518470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUEEN | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | ARPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295263572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432484700 | ||||||||
| FaxNumber: | 8432483145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295263572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432484700 | ||||||||
| FaxNumber: | 8432483145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 1288 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | MQ0726325 | 01 | DEA NUMBER | OTHER |