Provider Demographics
NPI:1053066282
Name:QUENGA, NICOLLE LORETTA
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:LORETTA
Last Name:QUENGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E BONITA AVE APT 1110
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2755
Mailing Address - Country:US
Mailing Address - Phone:760-927-9729
Mailing Address - Fax:
Practice Address - Street 1:15940 QUANTICO RD STE 150
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1397
Practice Address - Country:US
Practice Address - Phone:760-927-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty