Provider Demographics
NPI:1558619957
Name:QUINTILLA, MERINESSA MACAYAON (PT)
Entity Type:Individual
Prefix:
First Name:MERINESSA
Middle Name:MACAYAON
Last Name:QUINTILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 THURBER ROAD
Mailing Address - Street 2:GENESIS - MATULAITIS NURSING HOME
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 THURBER ROAD
Practice Address - Street 2:GENESIS - MATULAITIS NURSING HOME
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260
Practice Address - Country:US
Practice Address - Phone:860-928-7976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist