Provider Demographics
NPI:1639152994
Name:QUATTLEBAUM, MARY LOU (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:QUATTLEBAUM
Suffix:
Gender:F
Credentials:CRNP
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 18488
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8488
Mailing Address - Country:US
Mailing Address - Phone:256-533-6311
Mailing Address - Fax:256-536-0801
Practice Address - Street 1:751 PLEASANT ROW NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-2537
Practice Address - Country:US
Practice Address - Phone:256-533-6311
Practice Address - Fax:256-536-0801
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1076934163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51530690OtherBCBS OF AL
AL891010260Medicaid
AL891010260Medicaid
AL051530690Medicare ID - Type Unspecified