Provider Demographics
NPI:1346261526
Name:NACILLA, JOHNNY QUE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:QUE
Last Name:NACILLA
Suffix:
Gender:M
Credentials:MD
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 2126
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-2126
Mailing Address - Country:US
Mailing Address - Phone:256-255-2500
Mailing Address - Fax:256-255-2501
Practice Address - Street 1:1750 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-3622
Practice Address - Country:US
Practice Address - Phone:256-255-2500
Practice Address - Fax:256-255-2501
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00020069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00188313OtherRAILROAD MEDICARE
AL051555314Medicaid
AL51000810OtherBC/BS OF ALABAMA
AL51000810OtherBC/BS OF ALABAMA
ALP00188313OtherRAILROAD MEDICARE