Provider Demographics
NPI:1710615620
Name:QUANIMPTEWA, THAYLIA N/A
Entity Type:Individual
Prefix:
First Name:THAYLIA
Middle Name:N/A
Last Name:QUANIMPTEWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HWY 264 MP388
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042
Mailing Address - Country:US
Mailing Address - Phone:928-737-6000
Mailing Address - Fax:928-737-6005
Practice Address - Street 1:HWY 264 MP388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:928-737-6005
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1125148247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid
AZ1125148Medicaid