Provider Demographics
NPI:1619617867
Name:PURHAM, QUIANNA JAZMONE
Entity Type:Individual
Prefix:
First Name:QUIANNA
Middle Name:JAZMONE
Last Name:PURHAM
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 1:1302 COVEY LN APT A
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2904 E STAN SCHLUETER LOOP # 70
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4813
Practice Address - Country:US
Practice Address - Phone:254-294-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician