Basic Information
| Provider Information | |||||||||
| NPI: | 1477926194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUINTANA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | YVONNE | ||||||||
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| NameSuffix: | I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 WILLRUSH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954015331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078895450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 CLEVELAND AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075760818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2015 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 31638 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.