Basic Information
| Provider Information | |||||||||
| NPI: | 1316662992 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | QUAMMIE | ||||||||
| FirstName: | KHADESHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 EVERETT ST | ||||||||
| Address2: | |||||||||
| City: | ST SIMONS IS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315224605 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 504 EVERETT ST | ||||||||
| Address2: | |||||||||
| City: | ST SIMONS IS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315224605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT015644 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.