Basic Information
| Provider Information | |||||||||
| NPI: | 1265528376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSWORTH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | QUENEAU | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUENEAU | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 70368 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974750120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689746 | ||||||||
| FaxNumber: | 5412462353 | ||||||||
| Practice Location | |||||||||
| Address1: | 3355 RIVERBEND DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413497600 | ||||||||
| FaxNumber: | 5416868330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | Y | Other Service Providers | Genetic Counselor, MS |
No ID Information.