Basic Information
| Provider Information | |||||||||
| NPI: | 1164694402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAQUENO | ||||||||
| FirstName: | JEANZEN MICHELLE | ||||||||
| MiddleName: | LINTAG | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LINTAG | ||||||||
| OtherFirstName: | JEANZEN MICHELLE | ||||||||
| OtherMiddleName: | BERNABE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1501 BLUEBALL AVE | ||||||||
| Address2: | |||||||||
| City: | LINWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190613922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6106729936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1078 S STATE ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199016925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026782397 | ||||||||
| FaxNumber: | 3026782399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0002167 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 295853 | 01 | DE | UNISON | OTHER | 1164694402 | 05 | DE | MEDICAID | 3761297000 | 01 | IBC PERSONAL CHOICE | OTHER | 12033691 | 01 | CAQH | OTHER |