Provider Demographics
NPI:1083282149
Name:WISNER, QUEENELLA
Entity Type:Individual
Prefix:
First Name:QUEENELLA
Middle Name:
Last Name:WISNER
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 1:1020 WOODLANE RD APT 70
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-3204
Mailing Address - Country:US
Mailing Address - Phone:267-401-7675
Mailing Address - Fax:
Practice Address - Street 1:1020 WOODLANE RD APT 70
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:NJ
Practice Address - Zip Code:08010-3204
Practice Address - Country:US
Practice Address - Phone:267-401-7675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide