Provider Demographics
NPI:1487691069
Name:QUILLEN, KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:QUILLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:520-290-0300
Mailing Address - Fax:520-298-9230
Practice Address - Street 1:6365 E TANQUE VERDE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3830
Practice Address - Country:US
Practice Address - Phone:520-290-0030
Practice Address - Fax:520-298-9230
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN029139363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ190282Medicare PIN
S54714Medicare UPIN