Provider Demographics
NPI:1033852306
Name:MATUTE-ISLAM, QUANIQUA (CNA)
Entity Type:Individual
Prefix:
First Name:QUANIQUA
Middle Name:
Last Name:MATUTE-ISLAM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 EASTBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8945
Mailing Address - Country:US
Mailing Address - Phone:470-294-2103
Mailing Address - Fax:
Practice Address - Street 1:6653 EASTBRIAR DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8945
Practice Address - Country:US
Practice Address - Phone:470-294-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
GACN0008918328374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide