Provider Demographics
NPI:1043388457
Name:QUINTANA, CAROL JOANN (CFNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JOANN
Last Name:QUINTANA
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:CERRO
Mailing Address - State:NM
Mailing Address - Zip Code:87519-0295
Mailing Address - Country:US
Mailing Address - Phone:575-586-1017
Mailing Address - Fax:
Practice Address - Street 1:2573 STATE HWY 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556-0290
Practice Address - Country:US
Practice Address - Phone:505-586-0315
Practice Address - Fax:505-586-0519
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR17060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47225Medicaid
NM47225Medicaid