Provider Demographics
NPI:1407680705
Name:FLORES QUEZADA, MIRIAN ALEJANDRA
Entity type:Individual
Prefix:
First Name:MIRIAN ALEJANDRA
Middle Name:
Last Name:FLORES QUEZADA
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 1:509 SITKA ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-1462
Mailing Address - Country:US
Mailing Address - Phone:931-494-0476
Mailing Address - Fax:
Practice Address - Street 1:461 POND APPLE RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2208
Practice Address - Country:US
Practice Address - Phone:931-920-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist