Provider Demographics
NPI:1609096627
Name:VANQUATHEM, CARRIE MARIE (MS, PT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:VANQUATHEM
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 80TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2419
Mailing Address - Country:US
Mailing Address - Phone:515-727-2348
Mailing Address - Fax:
Practice Address - Street 1:5406 MERLE HAY RD
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1209
Practice Address - Country:US
Practice Address - Phone:515-727-8750
Practice Address - Fax:515-727-8757
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA42911OtherWELLMARK BCBS