Provider Demographics
NPI:1679331441
Name:AMOS, MARQUITA DAVINA
Entity type:Individual
Prefix:
First Name:MARQUITA
Middle Name:DAVINA
Last Name:AMOS
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 1:2211 LAKE CLUB DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-3204
Mailing Address - Country:US
Mailing Address - Phone:614-704-5224
Mailing Address - Fax:616-515-2693
Practice Address - Street 1:2211 LAKE CLUB DR STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-3204
Practice Address - Country:US
Practice Address - Phone:614-704-5224
Practice Address - Fax:616-515-2693
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health