Provider Demographics
NPI:1699357483
Name:MINOR, MABLE
Entity Type:Individual
Prefix:MS
First Name:MABLE
Middle Name:
Last Name:MINOR
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 1:541 WILEY PARKER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2226
Mailing Address - Country:US
Mailing Address - Phone:731-203-0708
Mailing Address - Fax:
Practice Address - Street 1:541 WILEY PARKER RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2226
Practice Address - Country:US
Practice Address - Phone:731-203-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date: