Provider Demographics
NPI:1982987418
Name:QUIROZ-TENNEFOS, DESIREE LYNEA
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:LYNEA
Last Name:QUIROZ-TENNEFOS
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 1:3033 MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4235
Mailing Address - Country:US
Mailing Address - Phone:928-718-6308
Mailing Address - Fax:
Practice Address - Street 1:3175 GORDON DR
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3303
Practice Address - Country:US
Practice Address - Phone:928-757-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP047504164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse