Provider Demographics
NPI:1871378661
Name:STREET, QUIANNA
Entity type:Individual
Prefix:
First Name:QUIANNA
Middle Name:
Last Name:STREET
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 1:8450 CEDARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3251
Mailing Address - Country:US
Mailing Address - Phone:310-696-9555
Mailing Address - Fax:
Practice Address - Street 1:15900 W 10 MILE RD STE 211444
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2036
Practice Address - Country:US
Practice Address - Phone:310-696-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
177F00000X, 342000000X
CA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No177F00000XOther Service ProvidersLodging
No342000000XTransportation ServicesTransportation Network Company