Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 1288 | SC |
NPI | 1063518470 |
---|---|
Provider Name | Linda Lee Queen |
First Address | Conway, SC 29526-3572 |
Second Address | Conway, SC 29526-3572 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MQ0726325 | DEA NUMBER (01) |