Provider Demographics
NPI:1104314335
Name:HEYWARD, QUETRELL DOMINIQUE
Entity type:Individual
Prefix:MR
First Name:QUETRELL
Middle Name:DOMINIQUE
Last Name:HEYWARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEADOWLARK CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4564
Mailing Address - Country:US
Mailing Address - Phone:732-533-7382
Mailing Address - Fax:
Practice Address - Street 1:1 W. GATES
Practice Address - Street 2:3400 SPRUCE ST.
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program