Provider Demographics
NPI:1154846699
Name:QUEEN, PHYLLIS
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:QUEEN
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 1:674 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-903-0962
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 14
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2114
Practice Address - Country:US
Practice Address - Phone:410-650-2000
Practice Address - Fax:866-639-5353
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-06
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR119059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily