Basic Information
Provider Information | |||||||||
NPI: | 1225652902 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUAINTANCE | ||||||||
FirstName: | MINDY | ||||||||
MiddleName: | MANZELLA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300 HOUMA BLVD STE 204 | ||||||||
Address2: |   | ||||||||
City: | METAIRIE | ||||||||
State: | LA | ||||||||
PostalCode: | 700062924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5045037000 | ||||||||
FaxNumber: | 5045036730 | ||||||||
Practice Location | |||||||||
Address1: | 4228 HOUMA BLVD STE 410 | ||||||||
Address2: |   | ||||||||
City: | METAIRIE | ||||||||
State: | LA | ||||||||
PostalCode: | 700063021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5048833770 | ||||||||
FaxNumber: | 5048833711 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2020 | ||||||||
LastUpdateDate: | 05/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 212077 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 212077 | 01 | LA | NURSE PRACTITIONER LICENSE | OTHER |