Provider Demographics
NPI:1558356410
Name:ERICKSON, QUENBY LEA (DO)
Entity Type:Individual
Prefix:DR
First Name:QUENBY
Middle Name:LEA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4100 LACLEDE AVE
Mailing Address - Street 2:#102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2851
Mailing Address - Country:US
Mailing Address - Phone:618-256-7572
Mailing Address - Fax:618-256-7629
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-7572
Practice Address - Fax:618-256-7629
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02002378A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology