Provider Demographics
NPI:1609504075
Name:QUEEN, CASSIE JONELLE
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:JONELLE
Last Name:QUEEN
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 1:195 BURNSIDE RUN RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:WV
Mailing Address - Zip Code:26338-4500
Mailing Address - Country:US
Mailing Address - Phone:304-269-4373
Mailing Address - Fax:
Practice Address - Street 1:195 BURNSIDE RUN RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:WV
Practice Address - Zip Code:26338-4500
Practice Address - Country:US
Practice Address - Phone:304-269-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant