Provider Demographics
NPI:1366031684
Name:QUINN, MARTINE SHANTELLE
Entity Type:Individual
Prefix:
First Name:MARTINE
Middle Name:SHANTELLE
Last Name:QUINN
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 1:616 NEWTON CONEHATTA RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MS
Mailing Address - Zip Code:39345-9780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 NEWTON CONEHATTA RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-9780
Practice Address - Country:US
Practice Address - Phone:267-357-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904915163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice