Provider Demographics
NPI:1962862094
Name:WILEY, QUINN (MPM, ATC, LAT)
Entity type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:MPM, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 E 1300 N
Mailing Address - Street 2:
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-8260
Mailing Address - Country:US
Mailing Address - Phone:260-578-0685
Mailing Address - Fax:
Practice Address - Street 1:11130 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1735
Practice Address - Country:US
Practice Address - Phone:260-578-0685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002122A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer