Provider Demographics
NPI:1467218818
Name:QUAM, LEA M
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:M
Last Name:QUAM
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 1:1905 EAST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:701-202-1600
Mailing Address - Fax:
Practice Address - Street 1:1906 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4700
Practice Address - Country:US
Practice Address - Phone:701-202-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator