Provider Demographics
NPI:1093313371
Name:QUACKENBUSH, KAMRYN MARGARET
Entity Type:Individual
Prefix:
First Name:KAMRYN
Middle Name:MARGARET
Last Name:QUACKENBUSH
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 1:6353D COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1768
Mailing Address - Country:US
Mailing Address - Phone:206-734-1595
Mailing Address - Fax:
Practice Address - Street 1:401 S MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6359
Practice Address - Country:US
Practice Address - Phone:615-393-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1269103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103K00000XMedicaid