Basic Information
| Provider Information | |||||||||
| NPI: | 1619388329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUICK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD | ||||||||
| Address2: | BUILDING B, 3RD FLOOR | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 PHILADELPHIA DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377343516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363LC0200X | 16144-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0136162 | 05 | OH | MEDICAID |