Provider Demographics
NPI:1689206351
Name:QUIJANO, ANGELA M (AIDE)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:QUIJANO
Suffix:
Gender:F
Credentials:AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-3727
Mailing Address - Country:US
Mailing Address - Phone:937-718-5936
Mailing Address - Fax:
Practice Address - Street 1:100 W PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3727
Practice Address - Country:US
Practice Address - Phone:937-718-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH489435Medicaid