Provider Demographics
NPI:1386204121
Name:MACON, QUIENTESSA
Entity Type:Individual
Prefix:
First Name:QUIENTESSA
Middle Name:
Last Name:MACON
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 1:23838 VINCENT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-1053
Mailing Address - Country:US
Mailing Address - Phone:216-333-0009
Mailing Address - Fax:
Practice Address - Street 1:23838 VINCENT DR
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-1053
Practice Address - Country:US
Practice Address - Phone:216-333-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337478Medicaid