Provider Demographics
NPI:1508473083
Name:BWANG, QUEENTA M
Entity Type:Individual
Prefix:
First Name:QUEENTA
Middle Name:M
Last Name:BWANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:QUEENTA
Other - Middle Name:M
Other - Last Name:BWANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:843 REVERE VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3445
Mailing Address - Country:US
Mailing Address - Phone:144-365-7360
Mailing Address - Fax:
Practice Address - Street 1:843 REVERE VILLAGE CT
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3445
Practice Address - Country:US
Practice Address - Phone:144-365-7360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.176191.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse