Provider Demographics
NPI:1053028977
Name:RENNICK, QUEIONNA MONE (32WG07641300)
Entity type:Individual
Prefix:
First Name:QUEIONNA
Middle Name:MONE
Last Name:RENNICK
Suffix:
Gender:F
Credentials:32WG07641300
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 BELVIDERE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-6604
Mailing Address - Country:US
Mailing Address - Phone:551-344-5948
Mailing Address - Fax:
Practice Address - Street 1:203 BELVIDERE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-6604
Practice Address - Country:US
Practice Address - Phone:551-344-5948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG07641300335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier