Provider Demographics
NPI:1609117878
Name:QUENNEVILLE, MARK (CO, CPED)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:QUENNEVILLE
Suffix:
Gender:M
Credentials:CO, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-7625
Mailing Address - Country:US
Mailing Address - Phone:517-394-5850
Mailing Address - Fax:
Practice Address - Street 1:4424 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-7625
Practice Address - Country:US
Practice Address - Phone:517-394-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist