Provider Demographics
NPI:1134311046
Name:QUENNEVILLE, LOIS (PA)
Entity Type:Individual
Prefix:MRS
First Name:LOIS
Middle Name:
Last Name:QUENNEVILLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:LOIS
Other - Middle Name:
Other - Last Name:QUENNEVILLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:450 E SIGLER AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555-1726
Mailing Address - Country:US
Mailing Address - Phone:660-465-8511
Mailing Address - Fax:660-465-2513
Practice Address - Street 1:450 E SIGLER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1726
Practice Address - Country:US
Practice Address - Phone:660-465-8511
Practice Address - Fax:660-465-2513
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00249363A00000X
MO2010036798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127076103Medicaid